Crystal's MCW Coder Hub🧬 CPT Code 31238 — Nasal/Sinus Endoscopy, Surgical; with Control of Nasal Hemorrhage
Full Description
CPT 31238 describes a surgical nasal/sinus endoscopy performed for the purpose of controlling nasal hemorrhage (epistaxis) using endoscopic visualization. The surgeon inserts a rigid or flexible nasal endoscope transnasally to identify the source of bleeding within the nasal cavity or sinuses and then controls the hemorrhage using cauterization (bipolar, monopolar, or electrocautery), topical hemostatic agents, directed packing, or a combination of these techniques under direct endoscopic visualization.
The critical distinction of this code — compared to blind or tactile approaches — is that the endoscope is used to identify and directly treat the precise bleeding source. This allows for targeted cauterization of specific vessels (such as branches of the sphenopalatine artery, posterior septal vessels, or ethmoid tributaries) under magnified visualization, rather than relying on anatomic estimation alone.
31238 vs. 31241 — The Critical Distinction (Post-2018):
Prior to 2018, CPT 31238 was widely used and often applied to endoscopic sphenopalatine artery (SPA) procedures of all types, because no more specific code existed. In 2018, the AMA created CPT 31241 specifically for formal dissection and ligation of the sphenopalatine artery — a more technically demanding procedure requiring mucoperiosteal flap elevation, identification of the crista ethmoidalis, sphenopalatine foramen dissection, and clip application to the isolated artery and its branches.
| Code | Procedure | Technique |
|---|---|---|
| 31238 | Endoscopic control of nasal hemorrhage | Identify bleeding area, treat with cautery/packing; does NOT require formal vessel dissection or isolation |
| 31241 | Endoscopic ligation of sphenopalatine artery | Formal mucoperiosteal flap, foramen dissection, vessel isolation, and clip ligation of the SPA |
The AMA CPT Assistant and AAPC guidance is explicit: 31238 involves identifying the area of bleeding and treating it with cautery and/or packing; 31241 involves dissecting out and isolating the SPA as it enters the nose and directly ligating it. The 31241 is substantially more work (8.0 wRVU). After 2018, 31238 use has appropriately declined for formal SPA ligation cases as 31241 has replaced it for that specific technique.
Anatomic Context
The endoscopic approach in 31238 targets vessels within the posterior nasal cavity — primarily the territory of the sphenopalatine artery and its branches, which supply the posterior nasal septum (Kiesselbach’s plexus zone for anterior bleeds; Woodruff’s plexus for posterior bleeds) and the lateral nasal wall.
Primary Bleeding Sources Addressed by 31238:
│
├── Posterior septum
│ └── Posterior septal branches of sphenopalatine artery
│
├── Lateral nasal wall
│ └── Posterior lateral nasal branches of sphenopalatine artery
│ (accessible via middle meatus with endoscope)
│
├── Superior nasal cavity
│ └── Anterior/posterior ethmoid arterial tributaries
│ (ethmoid aa. = branches of ophthalmic/internal carotid)
│ (→ ligation addressed by 30915 if open approach)
│
└── Anterior nasal cavity
└── Kiesselbach's plexus (Little's area)
(usually addressed by 30901/30903, not endoscopy)
Code Family / Code Tree
Nasal Hemorrhage Control — Escalating Complexity (30901-31241)
│
├── CONSERVATIVE (Non-Endoscopic)
│ ├── 30901 - Anterior epistaxis control, simple
│ │ (limited cautery and/or packing)
│ │ Global: 000
│ │
│ ├── 30903 - Anterior epistaxis control, complex
│ │ (extensive cautery and/or packing)
│ │ Global: 000
│ │
│ ├── 30905 - Posterior epistaxis control; initial
│ │ (posterior nasal pack and/or cautery)
│ │ Global: 000
│ │
│ └── 30906 - Posterior epistaxis control; subsequent
│ (for recurrence after initial 30905)
│ Global: 000
│
├── ENDOSCOPIC
│ ├── 31238 ◄ YOU ARE HERE
│ │ Nasal/sinus endoscopy, surgical;
│ │ with control of nasal hemorrhage
│ │ Technique: Endoscopic visualization +
│ │ direct cautery/packing of bleeding site
│ │ Does NOT require formal SPA dissection
│ │ Global: 000
│ │
│ └── 31241 - Nasal/sinus endoscopy, surgical;
│ with ligation of sphenopalatine artery
│ Technique: Mucoperiosteal flap, crista
│ ethmoidalis identification, foramen
│ dissection, clip ligation of SPA
│ and branches
│ Global: 000
│ wRVU: 8.0 (substantially higher)
│
├── OPEN SURGICAL
│ ├── 30915 - Ligation arteries; ethmoidal arteries
│ │ Open medial canthal approach
│ │ Global: 090
│ │
│ └── 30920 - Ligation arteries; internal maxillary
│ artery, transantral (Caldwell-Luc)
│ Global: 090
│
└── INTERVENTIONAL RADIOLOGY (ALTERNATIVE)
└── 61626 - Transcatheter embolization, CNS head/neck
(arterial embolization of IMA/SPA)
IR approach, used when surgical options
fail or are contraindicated
The Nasal Endoscopy Base Code Rule
CPT 31238 is a surgical endoscopy — it inherently includes the diagnostic survey performed at the beginning of the procedure. The endoscopy code family follows the base code rule:
- 31231 (Diagnostic nasal endoscopy) is the base endoscopy for this family
- When multiple surgical sinus endoscopy codes are performed together, each is valued at its full fee minus the base endoscopy value (31231 = ~1.82 facility wRVU) to avoid duplication of the shared diagnostic survey
- 31238 alone does not require subtracting the base; the deduction applies only when combining multiple codes from the FESS family in the same operative session
Includes (Bundled — Do NOT Bill Separately)
The following are considered integral components of CPT 31238 and are not separately reportable when performed as part of the same hemorrhage control session:
- Diagnostic nasal endoscopy (31231) — the surgical endoscopy inherently includes diagnostic survey
- Nasal decongestion, topical anesthesia, and vasoconstrictive agent application as part of endoscopic preparation
- Placement of topical hemostatic agents (e.g., Surgicel, Gelfoam) under direct endoscopic visualization as part of the hemorrhage control
- Directed posterior nasal packing placed via endoscopic guidance during the same session
- Endoscopic cauterization (bipolar, monopolar, silver nitrate) of the bleeding vessel or mucosal site
- Suctioning and clot evacuation necessary to identify the bleeding source
- Post-procedure anterior packing if placed as part of the same hemorrhage control session
- All standard post-procedure care (global period — see below)
Excludes / Cannot Bill With (Same Side, Same Session)
| Code | Reason |
|---|---|
| 31231 (Diagnostic nasal endoscopy) | Bundled by NCCI — surgical endoscopy includes the diagnostic component; cannot bill separately on same date/side |
| 31241 (SPA ligation) | Do not bill 31238 and 31241 together for the same side on the same date — select the code that accurately reflects the technique used |
| 30901, 30903, 30905, 30906 | Conservative packing/cautery attempts preceding the endoscopic approach on the same date are bundled into 31238; do not bill both the failed conservative attempt and the endoscopic control on the same DOS |
| 30920 (Transantral IMA ligation) | Do not bill 31238 and 30920 for the same bleeding episode on the same day — select the definitive procedure code |
Note
Exception — Different Dates: If 30905 was performed yesterday and 31238 is performed today for recurrent bleeding, they are separately billable on their respective dates of service. Separate date of service = no bundling issue.
Exception — Different Anatomic Sites (Same Session): If the surgeon endoscopically controls a posterior septal bleed (31238) AND separately performs an unrelated anterior cauterization at Little’s area (30901 or 30903), billing both may be supportable with Modifier -59 or XS (Separate Structure) and documentation of two distinct bleeding sites. This scenario is uncommon and will attract payer scrutiny — medical necessity documentation must be airtight.
NCCI Reminder: CCI bundles 31231 into 31238. The only way to separately bill 31231 and 31238 on the same date is if they were performed at a distinctly separate session (e.g., diagnostic scope in the morning, ER hemorrhage control in the evening) — use Modifier -59 or XE (Separate Encounter) to unbundle.
Assistant at Surgery
Not applicable for Medicare. CPT 31238 carries an assistant-at-surgery indicator that does not support payment for an assistant surgeon under the Medicare Physician Fee Schedule. This is consistent with its classification as a relatively straightforward endoscopic procedure that does not typically require surgical assistance.
For commercial payers, policies vary. Some may authorize an assistant under extenuating circumstances with appropriate documentation. Always verify individual payer policies before billing an assistant modifier on 31238.
wRVU and Reimbursement
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU (wRVU) | ~3.21 | ~3.21 |
| Practice Expense RVU | ~4.10 | ~1.40 |
| Malpractice RVU | ~0.29 | ~0.19 |
| Total RVU (approx.) | ~7.60 | ~4.80 |
| Medicare National Rate (est.) | ~285 | ~185 |
| Typical Commercial Rate Range | 600 | 450 |
CY 2026 PE Methodology Note:
CMS finalized a 50% reduction in indirect practice expense RVUs for facility-based services in 2026, which significantly reduced facility-setting reimbursement across all otolaryngology endoscopy codes. The AAO-HNS estimated this impacts total allowed charges for ENT facility services by approximately -12%. The above facility RVU total reflects this post-2026 adjustment. Non-facility rates saw a slight positive adjustment as a counterbalance.
Comparative wRVU Context:
| Code | Description | wRVU |
|---|---|---|
| 30901 | Anterior epistaxis, simple | ~0.72 |
| 30903 | Anterior epistaxis, complex | ~1.18 |
| 30905 | Posterior epistaxis, initial | ~2.17 |
| 30906 | Posterior epistaxis, subsequent | ~2.50 |
| 31238 | Endoscopic hemorrhage control | ~3.21 |
| 31241 | Endoscopic SPA ligation | ~8.00 |
| 30920 | Transantral IMA ligation | ~8.52 |
Global Period
| Element | Detail |
|---|---|
| Global Period | 000 (Zero-day — endoscopic/surgical procedure) |
| Pre-op Day Included | None |
| Post-op Days Included | None |
| What’s Bundled | Services provided on the same day as the procedure related to the procedure |
A 000 global period means this is treated as a minor procedure with no post-operative package. Evaluation and management services are separately reportable on the same day if they are for a separately identifiable medical problem — but if the E/M leads directly to the decision to perform 31238 that same day, only the procedure is typically billed (or the E/M is billed with Modifier -25 to indicate a significant, separately identifiable service above and beyond the minor procedure pre-service evaluation).
Note on Modifier -25: Because the global period is 000 (minor procedure), a separately identifiable E/M provided the same day may be billed with Modifier -25 on the E/M code. The documentation must show that the E/M addressed a problem or decision separate from the pre-procedure assessment for 31238 itself.
Note
Contrast with 30920: The transantral IMA ligation (30920) carries a 090-day major surgery global, requiring Modifier -57 on any same-day decision-making E/M. CPT 31238’s 000-day global requires only Modifier -25 for same-day E/M billing, a much lower documentation burden.
HCC (Hierarchical Condition Category)
CPT 31238 is a surgical procedure code and does not directly map to HCC risk-adjustment categories. As with CPT 30920, HCC scoring is driven entirely by the ICD-10-CM diagnosis codes submitted on the claim.
The primary diagnosis for 31238 claims (R04.0, Epistaxis) is not an HCC-mapped condition under CMS-HCC v28. However, underlying etiology and comorbid conditions submitted alongside R04.0 may carry significant HCC relevance:
| Condition | ICD-10-CM | HCC Relevance |
|---|---|---|
| Hemophilia A or B | D66, D67 | HCC 46 (Coagulation Defects) |
| Coagulopathy / anticoagulant effect | D68.32, D68.9 | Monitor |
| Malignant neoplasm of nasal cavity | C30.0 | HCC 10-12 (Cancer) |
| Hereditary hemorrhagic telangiectasia | Q78.0 | Generally not HCC |
| Thrombocytopenia (various) | D69.3, D69.59 | Context-dependent |
| Hypertension | I10 | Not HCC but common and should be coded |
CPT 31238 itself: HCC Not Applicable. Accurate, specific ICD-10-CM coding of the underlying etiology is critical for proper risk adjustment — particularly in Medicare Advantage populations.
MS-DRG Applicability
CPT 31238 is primarily an outpatient/ASC/ED procedure and does not drive MS-DRG assignment. In the vast majority of cases, this procedure is performed in an ambulatory setting and MS-DRGs do not apply.
In rare cases where a patient with refractory posterior epistaxis requires inpatient admission (for resuscitation, hemodynamic monitoring, or co-existing severe coagulopathy) and 31238/31241 is performed during that stay, the facility codes the procedure using ICD-10-PCS (not CPT), and the case groups to an MS-DRG based on the principal diagnosis and PCS procedure codes.
For inpatient epistaxis cases, relevant MS-DRGs are identical to those described under CPT 30920:
| MS-DRG | Title |
|---|---|
| 150 | Epistaxis with MCC |
| 151 | Epistaxis without MCC |
Note
Because 31238 has a 000-day global and is a minor procedure by classification, the scenarios where inpatient admission is needed specifically for 31238-level care (versus 31241 or 30920) are uncommon. When they occur, full comorbidity and complication coding drives the DRG weight.
Common ICD-10-CM Diagnosis Codes Paired with CPT 31238
Primary Diagnosis
| ICD-10-CM | Description |
|---|---|
| R04.0 | Epistaxis — the singular, non-lateralized ICD-10-CM code for all nosebleeds regardless of side or location |
Contributing Etiologies (Code Additionally When Documented)
| ICD-10-CM | Description |
|---|---|
| I10 | Essential (primary) hypertension |
| I15.0-I15.9 | Secondary hypertension (renovascular, endocrine, other) |
| D68.32 | Hemorrhagic disorder due to extrinsic circulating anticoagulants (warfarin, heparin, DOACs) |
| D68.9 | Coagulation defect, unspecified |
| D69.3 | Immune thrombocytopenic purpura |
| D69.59 | Other secondary thrombocytopenia |
| D66 | Hereditary factor VIII deficiency (Hemophilia A) |
| D67 | Hereditary factor IX deficiency (Hemophilia B) |
| Q78.0 | Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) |
| J34.2 | Deviated nasal septum |
| J34.89 | Other specified disorders of nose and nasal sinuses |
| J33.0 | Polyp of nasal cavity (polyp as bleeding source) |
| C30.0 | Malignant neoplasm of nasal cavity (tumor as bleeding source) |
| D10.6 | Benign neoplasm of nasopharynx (e.g., juvenile angiofibroma) |
| S09.90XA | Unspecified injury of head, initial encounter (traumatic epistaxis) |
| T45.515A | Adverse effect of anticoagulants, initial encounter |
| T45.515D | Adverse effect of anticoagulants, subsequent encounter |
| Z79.01 | Long-term (current) use of anticoagulants |
| Z79.02 | Long-term (current) use of antithrombotics/antiplatelets |
Post-Procedure Encounters
| ICD-10-CM | Description |
|---|---|
| T79.2XXA | Traumatic secondary and recurrent hemorrhage, initial (rebleeding after procedure) |
| T79.2XXD | Traumatic secondary and recurrent hemorrhage, subsequent encounter |
| Z48.89 | Encounter for other specified surgical aftercare |
| Z09 | Encounter for follow-up examination after completed treatment |
Coding Examples
Example 1 — Posterior Epistaxis, Endoscopic Cauterization (Office or ASC)
Clinical Scenario: A 55-year-old male with history of hypertension presents to the ENT office with a persistent right-sided posterior nosebleed that failed to respond to an earlier anterior packing (30901) in the ED two days ago. The ENT physician uses a rigid 0° nasal endoscope to identify active bleeding from a posterior branch of the right sphenopalatine artery. The vessel is cauterized with bipolar electrocautery under direct visualization. A small absorbable hemostatic sponge is placed. Bleeding is controlled. No formal dissection or vessel isolation was performed.
CPT: 31238-RT - Nasal/sinus endoscopy, surgical; with
control of nasal hemorrhage, right side
ICD-10: R04.0 - Epistaxis
I10 - Essential hypertension
Note
The earlier 30901 performed in the ED two days ago is billed separately on that date. It is NOT bundled into today’s 31238 because they occurred on different dates of service.
Example 2 — Same-Day E/M and Endoscopic Hemorrhage Control
Clinical Scenario: An established ENT patient presents urgently to the office with active epistaxis. The physician evaluates the patient (establishing severity, reviewing medications, noting supratherapeutic INR in a warfarin patient), addresses the anticoagulation management plan, and then proceeds to perform endoscopic hemorrhage control with cauterization.
CPT 1: 99213-25 - Established patient E/M (level 3), Modifier -25
(Significant, separately identifiable E/M above
and beyond the minor procedure pre-service eval)
CPT 2: 31238-RT - Nasal/sinus endoscopy, surgical; with control
of nasal hemorrhage, right side
ICD-10: R04.0 - Epistaxis
D68.32 - Hemorrhagic disorder due to extrinsic anticoagulants
I10 - Essential hypertension
Z79.01 - Long-term use of anticoagulants
Note
Modifier -25 is applied to the E/M, not to 31238. Because 31238 has a 000-day global period (minor procedure), an E/M on the same day is separately reportable when it represents a significant, separately identifiable service. The documentation must show that the E/M addressed a problem distinct from the routine pre-procedure assessment.
Example 3 — Bilateral Endoscopic Hemorrhage Control
Clinical Scenario: Patient with hereditary hemorrhagic telangiectasia (HHT) presents with bilateral posterior epistaxis. The ENT surgeon endoscopically identifies and cauterizes bleeding telangiectasias on both sides of the posterior nasal cavity during the same operative session.
CPT: 31238-50 - Nasal/sinus endoscopy, surgical; with control
of nasal hemorrhage, bilateral
(OR: 31238-LT and 31238-RT on separate lines per
payer preference — verify bilateral policy)
ICD-10: R04.0 - Epistaxis
Q78.0 - Hereditary hemorrhagic telangiectasia
Note
Example 4 — 31238 Performed with Concurrent Sinus Surgery
Clinical Scenario: A patient is undergoing planned FESS (bilateral total ethmoidectomy, 31255-50) when unexpected intraoperative posterior hemorrhage requires endoscopic cauterization of the right sphenopalatine territory. The surgeon controls the hemorrhage endoscopically before completing the planned procedure.
CPT 1: 31255-50 - Nasal/sinus endoscopy, surgical; with
ethmoidectomy, total (anterior and posterior),
bilateral
CPT 2: 31238-RT-51 - Nasal/sinus endoscopy, surgical; with control
of nasal hemorrhage, right; Modifier -51
(Multiple Procedures)
ICD-10: J32.2 - Chronic ethmoidal sinusitis (primary for FESS)
R04.0 - Epistaxis (for 31238)
Note
Multiple surgical endoscopy codes in the same session follow the base endoscopy deduction rule — the second code is valued at its full fee minus the base endoscopy value (31231). Modifier -51 signals the secondary procedure. Ensure the operative report documents the epistaxis control as a distinct, separately necessary service from the planned FESS.
Example 5 — 31238 vs. 31241 — Choosing the Correct Code Post-2018
Scenario A — Correct 31238 Use: The surgeon inserts an endoscope, visualizes active bleeding from the right posterior nasal cavity near the posterior attachment of the middle turbinate, and applies bipolar cautery directly to the bleeding mucosal vessel. No mucoperiosteal flap is elevated. No foramen dissection is performed. Vessel identity as the SPA is presumed based on location but not confirmed by dissection.
CPT: 31238-RT - Correct — no formal SPA dissection/isolation performed```
Scenario B — Correct 31241 Use: The surgeon elevates a mucoperiosteal flap from the lateral nasal wall, identifies the crista ethmoidalis, opens the sphenopalatine foramen, traces out the SPA and its two main branches, and applies endoscopic clips to each branch under direct visualization.
CPT: 31241-RT - Correct — formal sphenopalatine artery ligation with
mucoperiosteal flap, foramen dissection, and clipping
Warning
Audit Risk: Billing 31241 (8.0 wRVU) when only 31238-level (3.21 wRVU) cautery was performed is a significant upcoding risk. The operative note must clearly describe mucoperiosteal flap elevation, crista ethmoidalis identification, and sphenopalatine foramen dissection to support 31241. If those elements are not present in the report, 31238 is the correct code.
Example 6 — Failed 31238, Escalation to 31241 Same Session
Clinical Scenario: The surgeon attempts endoscopic cauterization (31238 level), but hemorrhage persists and the decision is made to formally dissect and ligate the SPA in the same operative session.
CPT: 31241-RT - Select only 31241; the 31238-level attempt
is bundled into the more definitive 31241 work
ICD-10: R04.0 - Epistaxis
I10 - Essential hypertension
Important
Do NOT bill both 31238 and 31241 for the same side during the same session. If the case escalated to formal ligation, bill only 31241 — it includes the diagnostic/exploratory work and the initial cauterization attempt.
Key Coding Pearls
- 31238 is the workhorse epistaxis endoscopy code for non-SPA-ligation scenarios. Since 31241 was introduced in 2018, the appropriate use of 31238 has narrowed to cases where endoscopic hemorrhage control is achieved via cauterization, topical agents, or directed packing without formal SPA dissection and ligation.
- Global 000 = no post-op package. Unlike 30920 (090 global), follow-up packing removal, repeat office endoscopy, or return visits after 31238 are separately billable. There is no surgical global period to worry about, but standard Medicare bundling for same-day related services still applies.
- Modifier -25 (not -57) for same-day E/M. Because the global period is 000 (minor procedure), use Modifier -25 on a same-day E/M — not Modifier -57. Modifier -57 is reserved for the E/M where the decision for major surgery (090 global) is made.
- Document the technique precisely. The operative report must specify: approach (endoscopic/transnasal), the endoscope used (0°, 30° rigid; or flexible), method of hemorrhage control (bipolar cautery, monopolar, Surgicel, packing type), location of bleeding site identified, and whether the procedure was unilateral or bilateral. Vague documentation such as “nasal endoscopy and cauterization performed” without detail is insufficient and invites denial or audit.
- NCCI bundling of 31231 into 31238 is absolute for same session. Never bill diagnostic endoscopy (31231) separately from 31238 on the same date unless they were performed at genuinely separate sessions (separate encounter modifier -XE or -59 required, with strong documentation support).
- Frequency and medical necessity. Unlike visual field tests with defined LCD frequency limits, epistaxis endoscopy frequency is driven by clinical recurrence. Each new episode of bleeding requiring endoscopic control on a new date of service is separately billable. Document that the bleeding recurred, why, and that escalated intervention was medically necessary.
- CY 2026 facility RVU impact. The CMS 2026 facility PE RVU reduction has disproportionately affected ENT facility-based codes. If your practice has shifted toward hospital-employed or facility-based settings, the reimbursement for 31238 in a facility POS is meaningfully lower than in prior years. Consider this when assessing site-of-service decisions for elective epistaxis management.
- Modifier -22 (Increased Procedural Services). If the hemorrhage control was substantially more complex than typical (e.g., prior nasal surgery distorting anatomy, active profuse bleeding obscuring endoscopic visibility requiring repeated repacking throughout, concurrent coagulopathy management in the OR), document all factors in the operative report and consider appending Modifier -22 with a supporting letter. Expect 15-30% additional reimbursement if approved.
- Packing removal is not separately billable (for most payers). The removal of nasal packing in the office after an endoscopic procedure does not have a specific CPT code. It is generally billed as an E/M service, even during the brief 000-day global window. Document the encounter and the clinical status assessment — do not attempt to report a separate procedure code for simple packing removal.