Ever wondered why ENT practices perform better financially than other specialties? ENT issues are prevalent. So, the volume of patients is high. Secondly, the reimbursement for ENT services and procedures is quite good. When compounded for hundreds of thousands of patients, this can pay off well.
However, all this financial stability can be temporary if practices start having billing issues. Billing issues trigger claim denials, which lead to reduced cash flow and decreased revenue generation. CPT code 31237 is a billing code that often keeps ENT billers on their toes. Why? Because of its dual nature and complex documentation.
That is why our expert billers at MediBillMD have compiled this detailed guide on CPT code 31237.
CPT Code 31237 – Description
The official definition of CPT code 31237 is:
Nasal/sinus endoscopy, surgical; with biopsy, polypectomy, or debridement (separate procedure)
Sounds hard? Let’s break this down in simpler terms.
Code 31237 is used to bill a surgical nasal/sinus endoscopy procedure that includes biopsy,
polypectomy, or debridement as a separate procedure. During the procedure, the physician inserts an endoscope into the nasal cavity. The endoscopy aids in clearly viewing the nasal contents and sinus structures, which would not have been possible with other methods.
During this examination, the physician may also perform various therapeutic actions, like removing polyps (polypectomy), taking tissue samples for pathological examination (biopsy), or cleaning out infected material and debris (debridement).
On average, the entire process lasts about 30 minutes to an hour. Another essential point to note is that the procedure requires anesthesia, sometimes local and sometimes general. This might vary from case to case depending on the complexity. However, CPT code 31237 does not cover reimbursement for general anesthesia, and billers must use additional anesthesia codes for it.
Scenarios Where CPT Code 31237 is Applicable
Nasal endoscopies are common. However, not every nasal endoscopy with tissue removal qualifies for this code. You will have to evaluate each case individually to determine if the procedure meets the criteria for separate billing. To give you an idea about its usage, let’s look at a couple of real-world scenarios in which it can be used:
Chronic Sinusitis
Let’s suppose a patient comes to an ENT specialist. He is feeling common symptoms of chronic sinusitis, like facial pain, pressure, and nasal obstruction. He is also unresponsive to conservative treatments.
As a possible treatment, the ENT specialist performs a nasal endoscopy. During the procedure, the physician identifies inflamed sinus tissue and uses endoscopy to debride the infected material and clear blocked passages. In this scenario, the physician will bill the entire procedure using CPT code 31237.
Post-Operative Debridement
The most common scenarios where CPT 31237 is appropriately billed include post-operative debridement procedures performed as unrelated services during the global period of another surgery.
For example, if a patient undergoes septoplasty and later requires debridement for an unrelated sinus issue, the ENT practitioner can report 31237 with the appropriate modifier.
Applicable Modifiers for CPT Code 31237
The following modifiers are commonly appended to CPT code 31237 to explain to the insurance payer the special circumstances under which the procedure was performed.
| Modifier | Description | When to Use |
|---|---|---|
| 50 | Bilateral Procedure | When performing debridement on both sides during the same session. |
| 51 | Multiple Procedures | When 31237 is performed with other procedures during the same surgical session. |
| 59 | Distinct Procedural Service | When 31237 is performed alongside other procedures that might otherwise be bundled. |
| 78 | Unplanned Return to Operating Room | When debridement becomes necessary due to complications from the original surgery. |
| 79 | Unrelated Procedure During Global Period | When billing 31237 during the global period of another procedure. |
CPT Code 31237 – Billing & Reimbursement Guidelines
The following billing tips and guidelines will help you submit error-free claims and secure fast and accurate reimbursements for your services.
Follow the Documentation Requirements
Appending the necessary documentation with your claims is essential to prove the procedure’s medical necessity. Without proper documentation, your claims will get denied. For CPT code 31237, the following documentation is necessary:
- Clear indication for the procedure.
- Detailed description of the endoscopic findings.
- Specific therapeutic interventions performed (biopsy, polypectomy, or debridement).
- Medical necessity justification.
- Anatomical locations involved.
Take Note of the Global Period
CPT 31237 has a zero-day global period. This means that related post-operative visits are not included in the procedure payment. This allows for separate billing of appropriate follow-up care when medically necessary.
Check the Reimbursement Amount
The reimbursement amount for CPT codes varies based on location and facility. The national average Medicare reimbursement for 31237 is $257.48 for non-facility settings and $156.23 for facility settings.
You can use Medicare’s PFS Lookup Tool to check the exact amount for your MAC locality.
Wrapping Up
Are you confused by all this information? Let’s do a quick recap. CPT code 31237 is used for billing nasal endoscopies, which may or may not include the removal of polyps (biopsy, debridement, or polypectomy). Key things to remember are to use a separate code for anesthesia and the appropriate modifiers (when necessary). 31237 is among the top 10 most used ENT codes, so its correct billing can create significant revenue for your practice.
We hope that these tips will help you prevent denials and improve your claims acceptance rate. However, if you are facing frequent denials or do not have a specialized billing team, consider outsourcing to get tailored ENT billing services.
