🧬 CPT Code 31288 - Endoscopic Sphenoidotomy with Tissue Removal

📋 Official Code Descriptor

Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus

🔬 Procedure Description

CPT 31288 describes a functional endoscopic sinus surgery (FESS) procedure in which the operating surgeon performs a sphenoidotomy — the surgical widening of the sphenoid sinus ostium — and removes tissue from within the sphenoid sinus cavity, all via an endoscopic approach through the nasal passages.^{AAPC Codify, 2025}

This is considered the “with tissue removal” counterpart to 31287 (Nasal/sinus endoscopy, surgical, with sphenoidotomy; without tissue removal). The key distinction is that 31288 requires documented entry into the sphenoid sinus with actual removal of tissue (e.g., polyps, thickened mucosa, fungal debris, granulation tissue) from the interior of the sinus — not merely widening the ostium.^{AAO-HNS / ENTnet, 2026}

Operative Steps (Typical)

The patient is brought to the OR and placed under general or local/monitored anesthesia care (MAC)
Nasal cavity is decongested topically (oxymetazoline or cocaine-soaked pledgets placed under endoscopic visualization)
Comprehensive diagnostic nasal endoscopy is performed; presurgical anatomy and findings are confirmed
The middle turbinate and sphenoethmoidal recess are identified
The natural sphenoid os is identified medial to the superior turbinate / in the sphenoethmoidal recess
The sphenoid sinus ostium is enlarged (sphenoidotomy) using through-cutting forceps, microdebrider, or Kerrison punch
The surgeon enters the sphenoid sinus cavity and removes pathologic tissue (polyps, infected mucosa, fungal debris, granuloma, etc.)
Hemostasis is achieved; absorbable packing may be placed
The procedure may be performed unilaterally or bilaterally — codes 31233-31297 are reported as unilateral procedures unless otherwise specified^{ENTnet CPT for ENT, 2026}

📂 Code Tree / Family

Nasal/Sinus Endoscopy - Accessory Sinuses (31233-31297)
│
├── [] - Diagnostic, with maxillary sinusoscopy (inferior meatus/canine fossa)
├── [] - Diagnostic, with sphenoid sinusoscopy
├── [] - Surgical, with biopsy, polypectomy, or debridement
├── [] - Surgical, with control of nasal hemorrhage
├── [] - Surgical, with dacryocystorhinostomy
├── [] - Surgical, with concha bullosa resection
├── [] - Surgical, with ligation of sphenopalatine artery(ies)
├── [] - Surgical, total (complete) ethmoidectomy, bilateral, with maxillary antrostomy...
├── [] - Surgical, with ethmoidectomy (partial)
├── [] - Surgical, with ethmoidectomy (total)
├── [] - Surgical, with maxillary antrostomy
├── [] - Surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
├── [] - Surgical, with frontal sinus exploration, with or without removal of tissue
├── [] - Surgical, with sphenoidotomy ← PARENT CODE (no tissue removal)
└── [] - Surgical, with sphenoidotomy; WITH removal of tissue ← THIS CODE

⚠️ Hierarchy Note: 31288 includes the work of 31287. You may NOT bill both 31287 and 31288 for the same sphenoid sinus in the same surgical session. Bill 31288 when tissue is removed from inside the sinus cavity.^{CMS NCCI Policy Manual Chapter 5, 2025}

✅ Includes

Sphenoidotomy (widening of sphenoid sinus ostium)
Endoscopic visualization of nasal cavity and sphenoethmoidal recess
Removal of tissue from within the sphenoid sinus (polyps, mucosa, fungal debris, granulation tissue)
Basic nasal endoscopy as part of the surgical approach
Topical decongestion and vasoconstriction as part of the procedure^{CMS NCCI Policy Manual Chapter 5, 2025}

🚫 Excludes / Do Not Report With

Code	Description	Reason
31287	Sphenoidotomy without tissue removal	Bundled — do not report with 31288 for same sinus same session
31297	Balloon dilation of sphenoid sinus ostium	Do not report 31297 with 31287 or 31288 for the same sinus^{ENTnet, 2026}
30130	Excision of inferior turbinate, partial or complete	Bundled into 31288 per NCCI edits^{CMS NCCI Chapter 5, 2025}
31235	Diagnostic sphenoid sinusoscopy	Diagnostic endoscopy is included in the surgical endoscopy
31231	Diagnostic nasal endoscopy	Included in the surgical endoscopy approach

💡 Per NCCI guidelines, when a surgical endoscopy is performed, the diagnostic endoscopy is always included and may not be separately reported. Additionally, CPT 30130 (excision of inferior turbinate) is specifically listed in NCCI edits as included and not separately reportable with 31288.^{CMS NCCI Policy Manual Chapter 5, 2025}

💰 RVU & Reimbursement Data (CY 2025 MPFS)

Component	Facility	Non-Facility
Work RVU (wRVU)	7.13	7.13
Practice Expense RVU	3.85	11.44
Malpractice RVU	0.94	0.94
Total RVU	11.92	19.51

💡 The conversion factor for CY 2025 is approximately $32.35 (subject to geographic adjustment via GPCI). Multiply total RVUs by the CF for an estimated payment amount.^{AMA, CY2025 MPFS Summary}

🗓️ Global Period & Surgical Indicators

Indicator	Value	Notes
Global Period	090	90-day global surgical package applies
Assistant Surgery	Not Payable (0)	Assistant surgeon not separately reimbursable by Medicare
Bilateral Indicator	1	If bilateral, bill with modifier 50; Medicare pays 150%
Co-Surgeon	0	Co-surgeon not applicable
Team Surgery	0	Team surgery not applicable
Multiple Procedure	2	Subject to multiple procedure reduction rules

📌 The 90-day global period means that routine pre-op (1 day before) and post-op visits for 90 days following the procedure are bundled into the payment for 31288. Separate E/M services during the global period require modifier 24, 25, or 79 depending on circumstance.^{UHC Global Days Policy; SGO Medicare Global Surgery Modifiers}

🔧 Common Modifiers Used with 31288

Modifier	Description	When to Use
50	Bilateral procedure	When procedure is performed on BOTH sphenoid sinuses in same session
LT	Left side	When performed unilaterally on the left
RT	Right side	When performed unilaterally on the right
22	Increased procedural services	Unusually complex case with documentation
51	Multiple procedures	When 31288 is one of several sinus procedures performed
59	Distinct procedural service	To bypass NCCI edits when procedures are truly separate/distinct
79	Unrelated procedure during global period	For unrelated surgery during 90-day global
58	Staged or related procedure	For planned staged procedures
XS	Separate structure	Alternative to 59 per CMS guidance (preferred by some MACs)

⚠️ When multiple sinus procedures are performed in the same session (e.g., 31288 + 31267 + 31255), apply modifier 51 to all procedures after the one with the highest RVU. However, always verify payer-specific bundling edits — many commercial payers and Medicare have NCCI edits that may require modifier 59 or XS to unbundle legitimately separate procedures.^{CMS NCCI Policy Manual, 2025}

🏥 MS-DRG (Inpatient Profee / Facility Context)

While CPT 31288 is most commonly performed in the outpatient or ambulatory surgery center (ASC) setting, when performed inpatient, the associated MS-DRGs are typically driven by the principal diagnosis:

MS-DRG	Description	Notes
MSA-DRG 152	Otitis Media & URI with MCC	May apply if sinusitis with significant comorbidities
MS-DRG 153	Otitis Media & URI with CC	Moderate complexity
MS-DRG 154	Otitis Media & URI without CC/MCC	Uncomplicated
MS-DRG 133	Other Ear, Nose, Mouth & Throat O.R. Procedures with MCC	Surgical DRG
MS-DRG 134	Other Ear, Nose, Mouth & Throat O.R. Procedures with CC
MS-DRG 135	Other Ear, Nose, Mouth & Throat O.R. Procedures without CC/MCC	Most common inpatient surgical DRG

Tip

📌 MS-DRG assignment for inpatient is driven by the principal diagnosis + ICD-10-PCS procedure codes in the facility setting, not CPT codes. CPT 31288 is relevant in the profee (professional fee) context for inpatient billing. The ICD-10-PCS equivalent for inpatient facility coding would be in the 9WH or 09U series (Medical and Surgical, Ear, Nose, Sinus).^{CMS ICD-10-PCS, 2025}

🦠 Associated ICD-10-CM Diagnoses

These are the most clinically appropriate and commonly paired diagnoses with CPT 31288:

Primary Diagnoses (Medical Necessity)

ICD-10-CM	Description	HCC?	Notes
J32.3	Chronic sphenoidal sinusitis	❌ No HCC	Most common primary diagnosis
J32.4	Chronic pansinusitis	❌ No HCC	When all sinuses involved
J32.8	Other chronic sinusitis	❌ No HCC	Multiple sinus involvement not elsewhere classified
J32.9	Chronic sinusitis, unspecified	❌ No HCC	Use only if more specificity not available
J33.0	Polyp of nasal cavity	❌ No HCC	Nasal polyps extending to/involving sphenoid
J33.8	Other polyp of sinus	❌ No HCC	Polyps specifically of sinus cavities
J33.9	Nasal polyp, unspecified	❌ No HCC	Less specific; use J33.8 if documentation supports
B44.1	Other pulmonary aspergillosis	❌ No HCC	Fungal sinusitis — Aspergillus
B44.81	Allergic bronchopulmonary aspergillosis	❌ No HCC	Allergic fungal sinusitis (AFS) presentation
J36	Peritonsillar abscess	❌ No HCC	Rare; extension of sinonasal abscess
D14.0	Benign neoplasm of middle ear, nasal cavity, accessory sinuses	❌ No HCC	Benign mass/tumor in sphenoid
C31.3	Malignant neoplasm of sphenoidal sinus	✅ HCC 12	Malignancy — significant HCC weight
J01.30	Acute sphenoidal sinusitis, unspecified	❌ No HCC	Acute — less common indication

💡 HCC Note: The vast majority of diagnoses paired with 31288 are not HCC-mapped in the CMS-HCC model, as chronic sinusitis and nasal polyps are not considered high-cost conditions for risk adjustment purposes. However, if the underlying etiology is a malignancy (e.g., C31.3) or a complicating systemic condition (e.g., granulomatosis with polyangiitis M31.30), HCC mapping may apply.^{CMS HCC Model V28, 2024}

💡 Coding Tips & Clinical Notes

Bilateral vs. Unilateral: Codes in the 31233-31297 series are unilateral by default. If the surgeon performs sphenoidotomy with tissue removal on both the right AND left sphenoid sinuses, report 31288--50 (or 31288--LT and 31288--RT on separate lines depending on payer preference).^{ENTnet CPT for ENT, 2026}
31287 vs. 31288: Use 31287 when the sphenoid ostium is simply opened/enlarged. Use 31288 when the surgeon enters the sinus and removes tissue from within the sphenoid sinus. The operative note must clearly document that tissue was removed from inside the sinus cavity — not just from the ostium.^{ENTnet CPT for ENT, 2026}
Balloon Dilation Exclusion: If the surgeon uses balloon dilation (31297) for the sphenoid sinus, do not separately report 31287 or 31288 for that same sinus in the same session. This is an exclusive relationship.^{ENTnet CPT for ENT, 2026}
NCCI Edits - Turbinate: Per CMS NCCI, 30130 (inferior turbinate excision) is bundled into 31288 and cannot be separately reported.^{CMS NCCI Chapter 5, 2025}
Documentation Requirements: The operative report must support: (1) endoscopic approach, (2) sphenoidotomy performed, (3) entry into the sphenoid sinus, (4) specific description of tissue removed, (5) laterality.

📝 Coding Scenarios / Examples

Scenario 1 - Straightforward Bilateral FESS with Sphenoid Tissue Removal

Op Note Summary: Patient with chronic pansinusitis and nasal polyposis. Surgeon performs bilateral total ethmoidectomy, bilateral maxillary antrostomy with tissue removal, and bilateral sphenoidotomy with polypoid tissue removed from both sphenoid sinuses.

CPT Codes:

31288--50 - Bilateral sphenoidotomy with tissue removal
31267--50--51 - Bilateral maxillary antrostomy with tissue removal
31255--50--51 - Bilateral total ethmoidectomy

ICD-10-CM:

J32.4 - Chronic pansinusitis
J33.8 - Polyp of sinus

Scenario 2 - Unilateral Sphenoid Tissue Removal with Frontal Sinus Exploration (Same Session)

Op Note Summary: Patient with chronic left sphenoidal sinusitis and left frontal sinusitis. Surgeon performs left-side sphenoidotomy with tissue removal and left frontal sinus exploration with tissue removal.

CPT Codes:

31288--LT - Left sphenoidotomy with tissue removal
31276--LT--51 - Left frontal sinus exploration with tissue removal

ICD-10-CM:

J32.3 - Chronic sphenoidal sinusitis
J32.1 - Chronic frontal sinusitis

Scenario 3 - Sphenoid Fungal Sinusitis, Debridement

Op Note Summary: Patient with known allergic fungal sinusitis, right-sided. Right sphenoidotomy performed with removal of fungal debris and polypoid tissue from the right sphenoid sinus.

CPT Codes:

31288--RT - Right sphenoidotomy with tissue removal

ICD-10-CM:

B44.81 - Allergic bronchopulmonary aspergillosis (or applicable fungal code)
J32.3 - Chronic sphenoidal sinusitis

Scenario 4 - Attempted Sphenoidotomy, Balloon Used Instead

Op Note Summary: Surgeon initially attempted traditional sphenoidotomy but converted to balloon dilation of the sphenoid ostium. No separate tissue removal performed.

CPT Codes:

31297 - Balloon dilation of sphenoid sinus ostium (Do NOT also bill 31287 or 31288 for same sinus)

Code	Description
31231	Nasal endoscopy, diagnostic
31235	Nasal/sinus endoscopy, diagnostic, with sphenoid sinusoscopy
31237	Surgical endoscopy with biopsy, polypectomy, or debridement
31254	Surgical endoscopy with ethmoidectomy, partial
31255	Surgical endoscopy with ethmoidectomy, total
31267	Surgical endoscopy, maxillary antrostomy with tissue removal
31276	Surgical endoscopy, frontal sinus exploration ± tissue removal
31287	Sphenoidotomy, without tissue removal
31297	Balloon dilation of sphenoid sinus ostium
30130	Excision inferior turbinate (bundled w/ 31288)

^{Sources: AAPC Codify CPT 31288, 2025; CMS NCCI Medicare Policy Manual Chapter 5, January 2025; AAO-HNS/ENTnet “CPT for ENT: Balloon Sinus Dilation,” March 2026; MD Clarity CPT 31288, 2024; Anthem Medical Policy CG-SURG-24 FESS, January 2025; CMS HCC Model V28, 2024; AMA CY2025 MPFS Summary; SGO Medicare Global Surgery Modifiers; UHC Global Days Policy.}

Explorer

31288

🧬 CPT Code 31288 - Endoscopic Sphenoidotomy with Tissue Removal

📋 Official Code Descriptor

🔬 Procedure Description

Operative Steps (Typical)

📂 Code Tree / Family

✅ Includes

🚫 Excludes / Do Not Report With

💰 RVU & Reimbursement Data (CY 2025 MPFS)

🗓️ Global Period & Surgical Indicators

🔧 Common Modifiers Used with 31288

🏥 MS-DRG (Inpatient Profee / Facility Context)

🦠 Associated ICD-10-CM Diagnoses

Primary Diagnoses (Medical Necessity)

💡 Coding Tips & Clinical Notes

📝 Coding Scenarios / Examples

Scenario 1 - Straightforward Bilateral FESS with Sphenoid Tissue Removal

Scenario 2 - Unilateral Sphenoid Tissue Removal with Frontal Sinus Exploration (Same Session)

Scenario 3 - Sphenoid Fungal Sinusitis, Debridement

Scenario 4 - Attempted Sphenoidotomy, Balloon Used Instead

🔗 Related Codes Quick Reference

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