Complete Guide to CPT 31267: Endoscopic Maxillary Antrostomy With Tissue Removal 2026 Billing, Coding & Reimbursement

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Everything ENT practices and sinus surgery billing teams need to know about CPT 31267 in 2026 including procedure overview, documentation requirements, ICD-10 pairing, modifier rules, denial prevention, reimbursement insights, and expert billing strategies from MedCloudMD.

CPT 31267 Endoscopic Maxillary Antrostomy With Tissue Removal — Unilateral

$420–$680 Average 2026 Reimbursement Non-Facility Rate

25–35% Typical Denial Rate Without Specialty Billing Support

J32.0–J33.9 Primary ICD-10 Range Sinusitis & Nasal Polyps

THE 2026 ENT BILLING REALITY

Why CPT 31267 Claims Are Harder to Get Paid Than They Should Be

Endoscopic sinus surgery is among the most technically demanding procedures in otolaryngology and it's also among the most billing-complex. CPT 31267, which covers endoscopic maxillary antrostomy with tissue removal, sits at the center of that complexity. It's a code that ENT practices bill frequently, a code that payers scrutinize heavily, and a code that generates a disproportionate share of denied and underpaid claims for practices without a structured specialty billing workflow.

The challenge isn't that CPT 31267 is obscure or rarely covered. Most major commercial payers and Medicare recognize it as a legitimate surgical service when performed for appropriate clinical indications. The challenge is the documentation, the coding combinations, the medical necessity requirements, the bilateral coding rules, and the payer-specific authorization requirements all of which must align perfectly for a claim to pay on first submission.

In 2026, that alignment is harder to achieve than ever. Payers have tightened their clinical coverage policies for functional endoscopic sinus surgery. Prior authorization requirements have expanded across United Healthcare, Aetna, and multiple Blue Cross Blue Shield plans. And the coding landscape for endoscopic sinus procedures has enough adjacent codes 31254, 31255, 31256, 31267 that miscoding is both common and costly.

This guide was written by MedCloudMD's ENT billing specialists to give your practice the specific knowledge it needs to bill CPT 31267 accurately, defend claims against denials, and capture the full reimbursement your surgical work earns.

FEATURED SNIPPET READY — 2026

What Is CPT 31267?

CPT 31267 describes a nasal/sinus endoscopy with maxillary antrostomy (surgical opening of the maxillary sinus) including removal of tissue from the maxillary sinus. It is a unilateral code when performed bilaterally, Modifier -50 or separate line items with -RT/-LT are required depending on payer requirements. CPT 31267 differs from CPT 31256 (simple antrostomy without tissue removal) by the additional work of removing tissue such as polyps, fungal debris, or diseased mucosa from within the maxillary sinus through the created opening.

CLINICAL FOUNDATION

What Is CPT 31267? Procedure Definition, Clinical Indications & Context

CPT 31267 appears in the Respiratory System section of the CPT code set under Nasal/Sinus Endoscopy. Understanding exactly what clinical work the code encompasses and what it doesn't is foundational to billing it correctly.

CPT 31267 Code Description (2026)

Nasal/sinus endoscopy, surgical; with maxillary antrostomy and removal of tissue from the maxillary sinus.

Breaking that description down into its clinical components: a nasal/sinus endoscopy is performed using a rigid nasal endoscope inserted through the nose. An antrostomy is created a surgically enlarged opening in the wall of the maxillary sinus (the ostiomeatal complex area) that improves drainage and ventilation. Through that opening, tissue is removed from within the sinus cavity. That tissue removal component is what distinguishes CPT 31267 from CPT 31256 (simple antrostomy without removal of sinus contents).

When Is CPT 31267 Used? Clinical Scenarios

PROCEDURE OVERVIEW — STEP BY STEP

What Happens During CPT 31267: Procedure Breakdown for Billing Purposes

Understanding the procedural steps helps billing teams ensure that operative reports capture the elements payers need to adjudicate the claim. Here's how an endoscopic maxillary antrostomy with tissue removal is performed and what documentation each step generates.

1

General or Local Anesthesia Administration CPT 31267 may be performed under general anesthesia or deep local anesthesia with sedation. The type of anesthesia is clinically relevant for billing because anesthesia is billed separately by the anesthesia provider. The surgeon's claim covers the surgical procedure itself. Documenting the anesthesia approach in the operative note is important for procedure justification but does not change the surgical CPT code.

2

Nasal Endoscope Placement and Cavity Inspection A rigid 0° or 30° nasal endoscope is introduced through the nostril. The nasal cavity, middle meatus, and ostiomeatal complex are inspected. Findings at this stage — polyps, edema, purulent discharge, or anatomical variants — should be specifically documented. These findings directly support the medical necessity for proceeding to antrostomy.

3

Uncinectomy (If Performed) The uncinate process is often removed to access the natural ostium of the maxillary sinus. When the uncinectomy is performed as part of the approach to the maxillary sinus (not as a standalone therapeutic procedure), it is considered integral to CPT 31267 and not separately billable. Billing CPT 31267 + a separate uncinectomy code for the same sinus is a bundling error.

4

Maxillary Antrostomy — Creating or Enlarging the Ostium The natural maxillary ostium is identified and surgically enlarged — the antrostomy. Tissue (diseased mucosa, polyps, crust, or other pathological material) is identified through the enlarged opening. The operative report must describe the creation of the antrostomy explicitly. Without documentation of this step, payers may downcode to CPT 31256 or deny entirely.

5

Tissue Removal from the Maxillary Sinus — The Differentiating Step Using curved forceps or a microdebrider, tissue is removed from within the maxillary sinus cavity through the antrostomy. This is the component that makes CPT 31267 distinct from CPT 31256. The operative report must specifically document the type of tissue removed (polyps, fungal debris, inspissated mucus, diseased mucosa), the method of removal, and the extent of clearance achieved. Pathology submission, when obtained, further supports this documentation.

6

Hemostasis and Closure (If Applicable) Hemostasis is achieved as needed. Absorbable packing or hemostatic agents may be placed. The operative report should note the bilateral or unilateral nature of the procedure and any additional procedures performed concurrently — which directly affects how the claim is coded and billed.

7

Post-Operative Documentation A complete, signed operative report must be available before the claim is submitted. Payers frequently request operative reports during medical necessity review, and a missing or inadequate op report is the primary reason for CPT 31267 claim denials that would otherwise have been paid.

BILLING & CODING GUIDELINES 2026

CPT 31267 Billing Guidelines, Documentation Requirements & Coding Rules

This is the section your billing team needs to understand completely before submitting any CPT 31267 claim. Getting these elements right on the first submission is the difference between a 95%+ acceptance rate and a 25–35% denial rate.

Complete Documentation Checklist — CPT 31267

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Operative Report — Complete and Specifically Documenting Tissue Removal The op report must explicitly describe the antrostomy creation AND the removal of tissue from the maxillary sinus. 'Standard FESS performed' is not sufficient. Specific findings (polyp type, volume of tissue, extent of clearance) are required.

☐	Pre-Operative CT Sinus Scan Documented Most payers require a CT scan of the sinuses (axial and coronal views) documenting pathology that supports the need for surgical intervention. CT findings must correlate with the surgical approach.

☐	Failed Medical Management Documentation Documentation of prior conservative treatment appropriate antibiotic courses, intranasal corticosteroids, saline irrigation is required to support medical necessity for surgical intervention with most commercial payers and Medicare.

☐	Pre-Authorization Number on Claim If prior authorization was required by the patient's plan, the authorization number must appear on the claim. Missing auth numbers result in automatic denial even when authorization was obtained.

☐	Bilateral vs. Unilateral Clearly Documented The operative report must explicitly state whether the procedure was performed on one or both sides. 'Bilateral FESS' in the procedure title is not sufficient — the body of the op report must describe each side's findings and work independently.

☐	Pathology Report (When Tissue Sent) When tissue is sent for pathological examination, the pathology report supports the documentation of tissue removal and the diagnosis codes submitted. Not always required, but strengthens the claim when available.

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Diagnosis Codes Matching Op Report Findings ICD-10 codes submitted must exactly reflect the pathology documented in the operative report. Billing J32.0 (chronic maxillary sinusitis) when the op report describes only acute findings, or missing a concurrent J33.0 (nasal polyps) code when polyps were the primary tissue removed, creates coding inconsistency that triggers review.

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Concurrent Procedures Correctly Coded Without Bundling When CPT 31267 is performed alongside other sinus codes (e.g., 31255 for ethmoidectomy, 31288 for sphenoid sinus), each code must represent distinct, separately documented surgical work. NCCI edits govern which code combinations are appropriate without a modifier.

Billing Component Requirements Table

💡  BILLING INSIGHT — 2026

In our experience reviewing ENT practice billing audits, the single most common CPT 31267 documentation failure is an operative report that describes the procedure generically without specifically calling out the tissue removal step. When a payer's auditor reviews the op report looking for the component that justifies 31267 over 31256, a note that says 'maxillary antrostomy performed, sinus inspected and cleaned' provides ambiguous support. A note that says 'maxillary antrostomy created with removal of approximately 2 cm³ of polypoid tissue from the lateral wall of the left maxillary sinus using curved forceps and microdebrider' is unambiguous. That specificity is what gets claims paid.

CPT CODE COMPARISON — ENDOSCOPIC SINUS SURGERY

CPT 31267 vs. Adjacent Sinus Surgery Codes — 2026 Comparison

Endoscopic sinus surgery coding involves a family of related codes. Selecting the correct code and correctly coding concurrent procedures requires understanding how these codes differ from one another and when each is appropriate.

CPT Code	Procedure Description	Key Difference from 31267	2026 Medicare Rate (Approx.)	Bundling Risk with 31267
31256	Nasal/sinus endoscopy with maxillary antrostomy — no tissue removal	No tissue removal from sinus cavity	$280–$360	N/A — 31267 replaces 31256 when tissue removed
31267	Nasal/sinus endoscopy with maxillary antrostomy + tissue removal	Tissue removal component present	$420–$560	Cannot bill 31256 same side same session
31254	Nasal/sinus endoscopy with partial ethmoidectomy — anterior	Ethmoid sinus, not maxillary	$320–$420	Separately billable when both performed — distinct sinus
31255	Nasal/sinus endoscopy with total ethmoidectomy — anterior + posterior	Total ethmoid clearance	$380–$500	Separately billable — distinct sinus; replaces 31254 same side
31288	Nasal/sinus endoscopy with sphenoid sinus surgery	Sphenoid sinus intervention	$350–$480	Separately billable — distinct sinus; not bundled with 31267
31276	Nasal/sinus endoscopy with frontal sinus exploration	Frontal sinus approach	$440–$590	Separately billable — distinct sinus approach
31294	Nasal/sinus endoscopy with optic nerve decompression	Optic nerve involvement	$820–$1,100	Separately billable — distinct, high-complexity procedure

⚠️  BILLING ALERT: Most Common Overcoding Error — 2026

Billing CPT 31256 AND CPT 31267 for the same maxillary sinus on the same side at the same session is a bundling violation. CPT 31267 already includes the antrostomy component of 31256. When tissue is removed, bill only 31267 for that side. When no tissue is removed, bill only 31256. Billing both triggers an NCCI edit denial — and in audit situations, can be flagged as inappropriate billing.

DENIAL PREVENTION — CPT 31267

Top CPT 31267 Denial Reasons in 2026 — and How to Beat Every One

Based on payer guidelines commonly observed in ENT billing audits, CPT 31267 claims deny for a predictable set of reasons. Understanding these patterns allows your billing team to address them systematically before claims submit, not after they deny.

Denial Frequency by Category — 2026 ENT Practice Data

The chart below reflects denial frequency patterns observed across ENT practices in 2026:

Percentages reflect share of total CPT 31267 denials across category — multiple denial reasons may apply to a single claim.

Denial Reason	Frequency 2026	Root Cause	Prevention Strategy	Appeal Approach
Medical Necessity — Insufficient Documentation	HIGH	Op report doesn't specifically document tissue removal; lacks failed medical therapy history	Op report template requiring tissue description; pre-op note capturing treatment history	Appeal with detailed op report, CT scan, prior treatment records, and AAO-HNS guideline citation
Prior Authorization Not Obtained	HIGH	Auth required but not verified before scheduling; wrong procedure code on auth request	5-day pre-procedure auth verification; confirm CPT code matches auth	Retroactive auth request — success varies by payer; prevention is the only reliable solution
Operative Report Inadequate	HIGH	Generic op report language without specific tissue removal documentation	Structured op report template with mandatory tissue removal documentation fields	Obtain addendum from surgeon clarifying tissue removal; resubmit with addendum
Incorrect Bilateral Modifier	MEDIUM-HIGH	Applied -50 when payer requires -RT/-LT or vice versa	Payer-specific modifier rule document; updated quarterly for all major payers	Corrected claim with correct modifier and payer policy documentation attached
NCCI Edit — Bundling	MEDIUM	31256 and 31267 billed same side same session	Claims scrubbing with NCCI edit checking; coding education for billing team	Identify if Modifier -59 is appropriate — only if distinct anatomical sites or separate sessions
ICD-10 Not Medically Necessary for Procedure	MEDIUM	Unspecified sinusitis codes when specific laterality/chronicity codes are available	Coder reviews op report and CT findings before selecting ICD-10 codes	Appeal with corrected ICD-10 code amendment and supporting documentation
Timely Filing Deadline Exceeded	LOW but costly	Denied claim sat unworked beyond payer filing window	7-day denial rework queue — no claim goes unactioned more than 7 business days	Very limited recovery options — prevents through process discipline

REAL-WORLD BILLING CHALLENGES — ENT 2026

Billing Challenges ENT Practices Face With CPT 31267 in 2026

Challenge 1 — The Concurrent Procedure Coding Trap

FESS procedures rarely involve a single sinus. Most CPT 31267 cases are performed alongside ethmoidectomy (31254 or 31255), and often include frontal (31276) or sphenoid (31288) sinus work. Billing this combination correctly requires understanding which codes represent distinct surgical work on distinct anatomical structures — and ensuring the operative report documents each component with the same specificity as it documents the maxillary work.

The most common coding error in multi-sinus FESS cases isn't the maxillary code — it's the downstream coding. Practices that default to a standard 'FESS bundle' without confirming each component against the operative findings regularly underbill by missing legitimately distinct procedures, or overbill by including codes for procedures that weren't actually performed.

💡  BILLING INSIGHT — 2026

A real pattern we see frequently in ENT billing audits: the surgeon performs bilateral FESS including maxillary antrostomy with tissue removal and anterior ethmoidectomy. The billing team submits CPT 31267-50 and CPT 31254-50. But the operative report shows that on the right side, total ethmoidectomy (31255) was performed, while only anterior ethmoidectomy (31254) was performed on the left side. The claim should be: 31267-RT, 31267-LT, 31255-RT, 31254-LT. The generic bilateral submission leaves legitimate revenue uncaptured and creates coding inconsistency that can trigger audit review.

Challenge 2 — Prior Authorization With the Right Procedure Code

In 2026, obtaining prior authorization for FESS is standard for most commercial plans — but the authorization must be obtained for the correct CPT codes. When a practice obtains authorization for CPT 31256 (simple antrostomy) and performs CPT 31267 (antrostomy with tissue removal), the claim submits against an authorization that doesn't match the procedure performed. The result is a claim denial that is difficult to appeal because the documentation of the performed procedure conflicts with the authorized procedure.

The solution is pre-surgical coding planning. Before requesting authorization, the billing team and surgeon should agree on the anticipated CPT codes based on preoperative imaging and clinical findings. Authorization should be requested for the expected range of procedures and updated if intraoperative findings significantly differ from the pre-operative assessment.

Challenge 3 — Medicare Advantage vs. Traditional Medicare

Traditional Medicare does not require prior authorization for CPT 31267 when performed in an outpatient setting with appropriate medical necessity documentation. Medicare Advantage plans, however which now cover more than 50% of Medicare-eligible patients frequently require prior authorization and apply coverage criteria that are more restrictive than traditional Medicare, even when they market themselves as Medicare plans. Practices that assume a Medicare card means traditional Medicare coverage are regularly caught by MA plan authorization requirements they didn't verify.

REIMBURSEMENT INSIGHTS 2026

CPT 31267 Reimbursement — What to Expect From Each Payer in 2026

Reimbursement for CPT 31267 varies by payer, geographic locality, facility type, and whether the claim is for unilateral or bilateral work. Tracking these figures against actual payments is the foundation of underpayment recovery a consistently underperformed function in ENT billing.

Payer Type	Unilateral Rate (Approx.)	Bilateral Rate (Approx.)	Auth Required?	Key Notes
Medicare (Traditional)	$380–$500	~$570–$750 at 150%	No	Published in CMS Physician Fee Schedule; locality-adjusted
Medicare Advantage	$400–$550	Varies by plan	YES — most plans	Plan-specific contracted rates; auth requirement universal in 2026
BCBS (Commercial)	$480–$680	$720–$1,020	YES — most plans	State-specific contracts; significant rate variability
UnitedHealthcare	$450–$630	$675–$945	YES	Updated 2026 policy — verify auth 7+ days pre-surgery
Aetna	$440–$610	$660–$915	YES	Clinical policy updated 2026; failed medical tx required
Cigna	$420–$590	$630–$885	YES — most plans	Contract-dependent; high-volume practices should renegotiate
Medicaid (State-specific)	$120–$280	Varies by state	Varies	Below-cost rates in most states; accept based on volume & patient mix

🔎  DID YOU KNOW? — 2026 Stat

ENT practices that run quarterly payment variance analysis on CPT 31267 claims — comparing actual payer payments against contractual allowable amounts — identify and recover underpayments averaging 8–14% of gross CPT 31267 collections annually. For a practice billing 80 sinus procedures per month, that's $40,000–$80,000 or more in recoverable annual revenue that is silently absorbed without a systematic review process.

ICD-10 CODING REFERENCE — CPT 31267

ICD-10 Codes Paired with CPT 31267 — 2026 Reference Guide

ICD-10 specificity is the most frequently cited documentation deficiency in CPT 31267 medical necessity denials. The table below covers the most clinically relevant and payer-accepted diagnosis codes for endoscopic maxillary antrostomy with tissue removal.

✅  EXPERT TIP

Never submit CPT 31267 with J32.9 (chronic sinusitis, unspecified) when the operative report and CT imaging specify maxillary sinus involvement. Using the correct code (J32.0) significantly improves first-pass acceptance because payers validate ICD-10 against their covered diagnosis lists for sinus surgery codes. J32.9 is a documentation failure that costs money unnecessarily.

MODIFIER USAGE — CPT 31267 2026

Which Modifiers Apply to CPT 31267 — and When

Modifier	Description	When to Apply	Payer Behavior	Common Error
-50	Bilateral procedure	Same-day bilateral maxillary antrostomy with tissue removal	Medicare and many commercial payers — reimburse at 150%	Using -50 when payer requires -RT/-LT instead
-RT / -LT	Right / Left side	Some payers prefer two separate line items over -50	Required by certain commercial plans — always verify	Not checking payer preference before submitting bilateral
-22	Increased procedural services	Significantly more complex procedure than standard — extensive disease, adhesions, prior surgery	Requires detailed operative note with specific complexity documentation	Using -22 without specific complexity documentation in op report
-51	Multiple procedures	Not applicable — CMS and most payers have own rules for multiple endoscopic procedures	N/A	Applying -51 to endoscopic sinus codes — incorrect in most sinus billing scenarios
-59	Distinct procedural service	When 31267 is billed with another code that triggers an NCCI edit but represents distinct work	Must represent truly distinct anatomical location or surgical session	Using -59 to bypass bundling edits without clinical justification
-76	Repeat procedure by same physician	Same procedure repeated on same sinus at a return visit or separate session same day	Requires distinct documentation of second intervention	Failing to append when legitimately repeating the procedure

REVENUE OPTIMIZATION STRATEGIES

Step-by-Step Revenue Optimization Tips for CPT 31267 Billing

These are the specific operational changes that produce the largest, fastest improvement in CPT 31267 reimbursement outcomes. Each recommendation is drawn from our direct work with ENT practices, not generic billing theory.

1.     Build a CPT 31267 Operative Report Template That Drives Clean Claims From the OR

The single highest-ROI investment any ENT practice can make in CPT 31267 billing is a structured operative report template that guides surgeons to document the specific elements payers require. The template should include mandatory fields for: anesthesia type, laterality (bilateral vs. unilateral with each side documented independently), findings at each surgical site, specific description of tissue removed (type, approximate volume, method), and a list of concurrent procedures with site-specific descriptions. A well-designed template takes five minutes to customize and can reduce CPT 31267 denials by 30–50%.

2.     Implement Pre-Surgical Coding Review for Every FESS Case

Before every endoscopic sinus surgery case is scheduled, a coding-qualified member of the billing team should review the pre-operative assessment and imaging findings and draft the anticipated CPT code set. This draft informs the authorization request, confirms the correct procedure codes are requested, and flags any anticipated coding challenges (e.g., concurrent procedures that may require modifier -59 or -22) before the case not after the operative note is written.

3.     Verify Prior Authorization for Each Payer 7 Business Days Before Surgery

Authorization verification should happen twice: once when the case is scheduled (to confirm the auth process is initiated) and once 7 business days before the procedure (to confirm the authorization is approved, covers the correct CPT codes, and has the correct date range). The authorization number must be documented in the billing record and included on the claim. This two-step verification eliminates retroactive denial situations that are difficult or impossible to recover.

4.     Run Monthly Payment Variance Analysis Against CPT 31267 Contractual Rates

Pull a monthly report of all CPT 31267 payments and compare each payer's actual payment against the contractual allowable for that payer's fee schedule. Underpayments exceeding 5% of the allowable should be flagged for dispute. For commercial payer underpayments, most payer contracts include a 90–180 day window to file a formal dispute. Missing that window forfeits the recovery opportunity permanently.

5.     Track CPT 31267 Denial Patterns Monthly Not One Claim at a Time

Generate a monthly report grouping all CPT 31267 denials by denial reason code and payer. Pattern-level analysis reveals systemic process failures that individual claim rework cannot solve. If 40% of your CPT 31267 denials from UHC are for medical necessity, that's a documentation workflow problem not 15 individual claim problems. Fix the upstream process, not just the downstream denials.

6.     Appeal Every Medical Necessity Denial With a Full Documentation Package Not a Resubmission

Medical necessity denials for CPT 31267 are frequently winnable on appeal — but only with the right documentation package. A bare resubmission of the same claim fails again. A proper appeal includes: the full operative report, the pre-operative CT scan report, the pre-operative assessment documenting failed medical therapy, a clinical letter from the surgeon specifically addressing the payer's denial rationale, and a citation of the payer's own clinical coverage policy showing that the documented case meets their stated coverage criteria.

WHY MEDCLOUDMD — ENT BILLING SPECIALISTS

Why ENT Practices Trust MedCloudMD With Their CPT 31267 Billing in 2026

Endoscopic sinus surgery billing requires a level of specialty knowledge that generalist billing teams rarely develop. The concurrent procedure coding, the bilateral modifier variability, the payer-specific prior authorization requirements, the NCCI edit compliance each demands expertise that's built through dedicated ENT billing experience, not general medical billing exposure.

MedCloudMD's ENT billing team was built around exactly that expertise. Here's what we deliver for practices billing CPT 31267 and the full FESS code set.

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Dedicated ENT Coding Team — Not a Generalist Pool Our ENT billing specialists work with CPT 31254, 31255, 31267, 31276, 31288 and the full sinus surgery code set every day. They understand NCCI edit pairs for concurrent sinus procedures, know the bilateral modifier preferences of every major payer, and verify ICD-10 specificity against operative reports before any claim transmits.

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Pre-Surgical Coding and Authorization Review For every scheduled FESS case, our team conducts a pre-surgical review: anticipated CPT codes confirmed, authorization status verified, concurrent procedure coding analyzed against planned surgical work. This proactive approach prevents the authorization mismatches and concurrent coding errors that drive CPT 31267 denials.

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Denial Management with 7-Day Rework SLA — Every Claim Every denied CPT 31267 claim enters our structured rework queue within 24 hours of receipt. Root cause is identified, the upstream process failure is corrected, and a substantive appeal is filed — with full documentation package, clinical letter, and payer policy citation — within 7 business days. We track denial outcomes by reason and payer to drive continuous improvement.

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Payment Variance Analysis — Monthly, Not Annual We run monthly payment variance analysis on every CPT 31267 claim, comparing actual payments against each payer's contracted allowable. Underpayments are flagged and disputed within contractual windows. For high-volume ENT practices, this process routinely recovers significant revenue that would otherwise be silently accepted below the contracted rate.

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Real-Time ENT Billing Analytics Dashboard Every MedCloudMD ENT client receives a real-time dashboard showing CPT 31267 first-pass acceptance rate, denial rate by reason code, AR aging by payer, bilateral billing accuracy, and collection rate versus allowable. Performance is visible, measurable, and consistently improving.

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Dedicated Account Manager — Not a Rotating Help Desk Your practice has a named ENT billing account manager who knows your payer mix, your surgeons' coding patterns, your authorization workflow, and your billing history. Strategic billing guidance requires that institutional knowledge — and it's what distinguishes a genuine billing partner from a claims processor.

Schedule Your Free ENT Billing Audit — CPT 31267 Focus

MedCloudMD analyzes your CPT 31267 denial rate, concurrent procedure coding accuracy, bilateral modifier consistency, and AR aging — at no cost. No obligation.

www.medcloudmd.com/specialties/ent-billing-services

FREQUENTLY ASKED QUESTIONS — CPT 31267 2026

CPT 31267 Billing FAQs — Answered by ENT Billing Specialists

Q: Is CPT 31267 a unilateral or bilateral code?

CPT 31267 is a unilateral code. When the procedure is performed bilaterally (on both maxillary sinuses in the same session), the code must be modified to indicate bilateral work. Most Medicare and commercial payers accept Modifier -50 on a single claim line for bilateral procedures, which typically results in reimbursement at 150% of the unilateral rate. Some commercial payers prefer two separate claim lines using Modifier -RT (right side) and Modifier -LT (left side). Using the wrong approach for a specific payer generates an automatic denial always verify bilateral coding requirements by payer before submitting.

Q: What is the difference between CPT 31256 and CPT 31267?

CPT 31256 describes nasal/sinus endoscopy with maxillary antrostomy the creation of a surgical opening in the maxillary sinus for drainage and ventilation without removal of tissue from inside the sinus. CPT 31267 includes all of that plus the removal of tissue from the maxillary sinus cavity through the created opening. The tissue removed may be polyps, fungal debris, inspissated mucus, or diseased mucosa. When tissue is removed from the sinus, bill only CPT 31267 — not both 31256 and 31267 for the same side at the same session, which is a bundling violation.

Q: Can CPT 31267 be billed with CPT 31255 or CPT 31254?

Yes — when the surgery addresses multiple sinuses, concurrent sinus procedure codes can be billed together when the operative report documents distinct surgical work in each sinus. CPT 31267 (maxillary) can be billed with CPT 31254 (partial anterior ethmoidectomy), CPT 31255 (total ethmoidectomy), CPT 31276 (frontal sinus exploration), or CPT 31288 (sphenoid sinus surgery) when all are performed and documented. However, NCCI edit compliance must be verified some code combinations require Modifier -59 to indicate distinct procedures. Claims scrubbing software with NCCI edit checking is essential for multi-sinus FESS billing.

Q: What documentation is required for CPT 31267 to avoid medical necessity denial?

To support medical necessity for CPT 31267, the medical record must document: (1) a CT scan of the sinuses showing pathology in the maxillary sinus typically within 6 months of surgery; (2) clinical notes documenting the patient's symptom history and frequency; (3) documentation of prior conservative medical management appropriate antibiotics, intranasal corticosteroids, and saline irrigation — that was insufficient to resolve the condition; and (4) a complete operative report specifically describing the antrostomy creation and the tissue removed from the maxillary sinus. Generic operative report language without specific tissue removal documentation is the most common reason for CPT 31267 medical necessity denials.

Q: Why do ENT sinus surgery claims get denied so frequently?

CPT 31267 and other FESS codes deny for several consistently recurring reasons in 2026: (1) medical necessity documentation that doesn't specifically describe the tissue removal component; (2) prior authorization not obtained or obtained for the wrong procedure code; (3) incorrect bilateral modifier for the specific payer's requirements; (4) NCCI bundling edit violations when concurrent sinus codes are billed incorrectly; (5) ICD-10 codes that are too unspecified to support the procedure; and (6) operative reports that use generic language insufficient to support specialty coding. All of these are preventable with specialty-specific billing workflows.

Q: Does Medicare require prior authorization for CPT 31267?

Traditional Medicare (Part A and B) does not require prior authorization for CPT 31267 when performed in an outpatient surgical setting with appropriate medical necessity documentation. However, Medicare Advantage plans which now cover more than 50% of Medicare beneficiaries frequently require prior authorization and may apply clinical coverage criteria that are more restrictive than traditional Medicare. In 2026, assuming a Medicare card means traditional Medicare coverage without verifying the specific plan is a common and costly mistake. Always verify the patient's specific plan and its authorization requirements.

Q: How does MedCloudMD improve CPT 31267 billing outcomes?

MedCloudMD's ENT billing specialists manage the complete CPT 31267 billing workflow — from pre-surgical coding review and prior authorization verification through clean claim submission, concurrent procedure coding, payment variance analysis, denial management, and appeal filing. We begin every ENT engagement with a complimentary billing audit that analyzes your CPT 31267 denial rate, bilateral coding accuracy, concurrent procedure coding patterns, and AR aging quantifying the specific revenue recovery opportunity for your practice. Visit www.medcloudmd.com/specialties/ent-billing-services to schedule your free audit.

Q: Can Modifier -22 (Increased Procedural Services) be used with CPT 31267?

Yes — Modifier -22 can be applied to CPT 31267 when the procedure was significantly more complex than typically required for a standard endoscopic maxillary antrostomy with tissue removal. Clinical scenarios that may support -22 include: extensive adhesions from prior surgery, severe polyposis requiring unusually prolonged removal, anatomical anomalies significantly complicating the procedure, or unusually difficult access. However, Modifier -22 requires specific, detailed documentation in the operative report describing exactly why and how the procedure was more complex — not just a general statement. Applying -22 without specific complexity documentation results in denial and potential audit flags.

FINAL THOUGHTS — 2026

CPT 31267 Is Billable. Make Sure You're Collecting Everything You're Owed.

Endoscopic maxillary antrostomy with tissue removal is a procedure your surgeons perform because it genuinely helps patients with chronic or recurrent maxillary sinus disease. The clinical work is real. The documentation requirements are clear. The payer coverage exists. And yet, in ENT practices across the country, CPT 31267 remains one of the most chronically underpaid and over-denied sinus surgery codes not because payers won't cover it, but because billing workflows consistently fail to document, code, authorize, and submit it at the level of specificity that gets it paid.

In 2026, with prior authorization requirements expanding, payer medical necessity policies tightening, and Medicare Advantage coverage displacing traditional Medicare for a growing share of your patients, the billing discipline required to reliably capture CPT 31267 revenue is higher than it's ever been. The practices that rise to that standard consistently with specialty-trained coders, pre-surgical coding reviews, structured op report templates, and systematic denial management collect 20–30% more revenue from the same surgical volume than those that treat it as a routine claim.

MedCloudMD's ENT billing team has built its practice around exactly that standard. If you're ready to find out what your CPT 31267 billing is currently leaving behind, our complimentary audit will give you the specific answer in your data, for your payers, for your practice. No obligation. The insights are yours to keep.

© 2026 MedCloudMD · ENT Billing Services · HIPAA-Compliant Revenue Cycle Management for Otolaryngology

CPT codes are owned by the American Medical Association. This guide is for educational purposes only and does not constitute legal or billing compliance advice.