Summary & Overview
CPT 31288: Endoscopic Sphenoid Sinus Surgery
CPT code 31288 defines an endoscopic sphenoidotomy in which an endoscope is inserted through the nasal cavity, the sphenoid sinus ostium is widened, and pathological or obstructing tissue is removed from the sphenoid sinus. This procedure is commonly performed for sphenoid sinus disease, including chronic rhinosinusitis, mucoceles, fungal disease, or access for skull base surgery, and matters nationally because it represents a frequently billed minimally invasive otolaryngology surgical service with implications for surgical resource use, site-of-service decisions, and payer coverage policies.
Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, typical sites of service (hospital outpatient departments and ambulatory surgery centers), and the role of 31288 within endoscopic sinus surgery care pathways. The publication presents benchmarks and comparators, highlights relevant billing and coding considerations, and outlines recent policy updates that affect coverage and site-of-service selection. It also provides practical guidance for coding accuracy and documentation expectations tied to clinical indications. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 31288 describes an endoscopic surgical procedure in which a provider inserts an endoscope into the nasal cavity, widens the sphenoid sinus opening, and removes tissue from the sphenoid sinus. This procedure is a type of endoscopic sinus surgery.
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Service type: Endoscopic sinus surgery, sphenoidotomy with debridement/removal of tissue
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Typical site of service: Hospital outpatient department or ambulatory surgery center; may also occur in an operating room setting due to the need for endoscopic equipment and potential anesthesia
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Clinical & Coding Specifications
Clinical Context
A typical patient is a 45–60-year-old adult presenting to an otolaryngology clinic with chronic sphenoid sinusitis, recurrent sphenoid sinus polyps, or a symptomatic isolated sphenoid sinus mucocele that has failed medical management. Symptoms include persistent deep-seated retro-orbital headache, postnasal drip, intermittent fevers, and purulent nasal drainage. Prior to surgery the patient undergoes nasal endoscopy and sinus CT imaging confirming a narrowed or obstructed sphenoid ostium and disease confined to the sphenoid sinus.
The clinical workflow includes preoperative evaluation (history, physical exam, anesthetic assessment), nasal decongestion and topical anesthesia in the operating room, and performance of transnasal endoscopic sphenoidotomy using an endoscope inserted through the nasal cavity. The surgeon widens the sphenoid sinus opening and removes inflammatory tissue, polyps, or mucus to re-establish drainage and ventilation. Intraoperative hemostasis is obtained, specimens may be sent for culture or pathology, and the patient is recovered in PACU with postoperative topical nasal care and scheduled follow-up for endoscopic surveillance and possible postoperative debridement in clinic.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the surgeon’s professional service separate from a facility technical component |