When can a nasal endoscopy and an office visit be billed together with modifier 25?

A nasal endoscopy and an office visit can both be paid on the same day, but far less often than the habit of adding modifier 25 to every scope-day visit suggests. CPT 31231 carries a 0-day global period, which means Medicare already pays for the evaluation that leads to the scope. The visit earns its own payment only when it does work the scope does not.

When does an office visit on a nasal endoscopy day qualify for modifier 25?

When the visit addresses something beyond the decision to scope. The NCCI Policy Manual is direct: the decision to perform a minor surgical procedure is included in the payment for that procedure, and a same-day E/M is separately reportable only when it is significant, separately identifiable and unrelated to that decision. Modifier 25 then goes on the E/M line, never on 31231.

The CMS Claims Processing Manual says the same thing another way: the E/M has to sit above and beyond the usual pre- and post-procedure work of the scope, such as confirming the indication, consent and explaining findings.

The decision to scope is part of the scope

Most scope-day claims fail here. A patient arrives with nasal obstruction, the physician takes a focused history, looks with a speculum, decides an endoscopy is needed and performs it. Everything before the scope is the decision. Billing 99213-25 for it asks Medicare to pay twice for the same minutes, and modifier 57 does not rescue it, because CMS limits 57 to the decision for major surgery with a 90-day global.

The American Rhinologic Society has made the same point while defending modifier 25: when 31231 was last valued, 12 minutes of pre-service time were removed to account for overlap with a same-day visit. The scope’s payment already assumes a visit often comes with it, which is why a visit limited to the decision is not paid twice.

A different diagnosis is not required, and a new patient is not enough

Two myths sit on either side of the rule. CMS states that different diagnoses are not required for modifier 25, so an E/M and a scope can both carry the same chronic sinusitis code and still both be payable. And NCCI states that a patient being new to the practice is not sufficient alone to justify the E/M. New patients often do qualify, but because their workup is broad, not because of their status.

How do you decide whether a scope-day visit is billable?

Run the encounter through five questions before the claim leaves the practice. If the answer to any of the first three is no, bill 31231 alone.

1. Is there work in the note other than deciding to scope? A second problem managed, a new complaint worked up, a medication changed for a separate condition, or a full new-patient evaluation of several complaints.
2. Would that work have been a billable visit if no scope had happened? This is the cleanest test reviewers apply. If removing the scope leaves only a referral note, there is no separate visit.
3. Is the E/M documented in its own section? History, exam and assessment for the visit, then a separate procedure note with indication, findings and the sides examined.
4. Is the E/M leveled without counting the scope? Medical decision making that rests on the scope findings belongs to 31231, not to the visit level.
5. Does the payer cut, review or deny modifier 25 lines? Check the contract and any modifier 25 policy before assuming Medicare rules carry over.

In our claim audit, same-day E/M visits billed with 31231 were denied for modifier 25 on 11% of claims, mostly on the first two questions.

What does the 31231 CPT code include, and what is the 31231 global period?

31231 is a diagnostic nasal endoscopy, unilateral or bilateral, flagged as a separate procedure. It covers inspection of the nasal cavity, meatuses, turbinates and sphenoethmoid recess with a rigid or flexible scope. Its global period is 000: no preoperative or postoperative days, but the same-day evaluation that led to the scope is included, which is the whole reason modifier 25 matters here. Our guide to the global surgical package across 000, 010 and 090 codes shows how that window works on other procedures.

Is 31231 the only diagnostic nasal endoscopy CPT code?

No. 31233 and 31235 are diagnostic endoscopies of the maxillary and sphenoid sinuses that require puncture or trocar entry, and both are unilateral. 92511 is nasopharyngoscopy, which examines the nasopharynx and eustachian tube openings rather than the nasal cavity. 31575 is flexible laryngoscopy.

Can 31231 be billed with 92511, 31575 or 31237 on the same day?

Rarely, and never by default. A diagnostic endoscopy is not separately reportable with a surgical endoscopy of the same area, so 31231 folds into 31237 debridement and the sinus surgery codes. NCCI also says a cursory look at the nasopharynx during another respiratory endoscopy is not reported as 92511, and 31575 is reportable with 31231 only when two separate scopes were medically necessary.

Can 31231 be billed bilaterally?

No. The descriptor already reads unilateral or bilateral, and the code carries bilateral indicator 2 in the fee schedule file, which Medicare contractors read as already priced as bilateral: one unit, no modifier 50. Several coding pages still recommend 50 here, which produces a denial or an overpayment.

What do CPT 31231 and a same-day visit pay in 2026?

At the 2026 conversion factor of 33.4009, 31231 pays $193.39 nationally in the office and $54.78 in a facility. That places the scope above 99215 at $192.39, 99204 at $177.36, 99214 at $135.61 and 99213 at $95.19. Among office visits, only 99205 at $236.81 pays more.

Worked example: a three-surgeon ENT group

Take a three-surgeon otolaryngology group collecting about $180,000 a month that performs 140 office scopes a month. Ninety of those scope days also carry a visit: 40 billed as 99213-25 and 50 as 99214-25. The scopes bring in $27,074.60 a month and the visits $10,588.10, so visit lines are about 28% of scope-day revenue.

Now apply the denial pattern. At an 11% modifier 25 denial rate, $1,164.69 a month in visit revenue comes back unpaid. In the average practice we review, 19% of denied claims were never reworked or appealed, which here leaves $221.29 a month, or $2,655.48 a year, written off without anyone deciding to write it off.

How would the 2027 proposed rule change scope-day payment?

It would pay the lower-valued service at half. In the CY2027 Physician Fee Schedule proposed rule, CMS proposes that when a separately identifiable office E/M is billed on the same day as a 0-, 10- or 90-day global procedure by the same practitioner or group, the more expensive service is paid in full and the other at 50%. CMS says the current approach is likely duplicating payment.

Because 31231 pays more than every office visit except 99205, the visit is almost always the line that gets halved. At 2026 rates, 31231 with 99213 would drop from $288.58 to $240.99, and 31231 with 99214 from $329.00 to $261.20. With 99205 the order flips: the visit is paid in full and the scope is halved, so the pair drops from $430.20 to $333.51.

The exposure for otolaryngology is unusually large. AAO-HNS told CMS that 31231 was reported with an office E/M on 85.4% of claims in 2024, and the proposed rule’s own impact table shows otolaryngology down 9% overall. For the group in the worked example, halving the 90 visit lines would remove $5,294.05 a month, or $63,528.60 a year, before the proposed conversion factor change to $32.84. This is still a proposal, with the final rule expected in early November, and our otolaryngology billing page tracks the wider ENT changes.

What has to be in the record to support the separate visit?

Two notes in one encounter, each able to stand alone. Reviewers read the E/M with the scope note covered up, and whatever is left has to justify the visit.

• Chief complaint and history for every problem addressed, not only the one that prompted the scope.
• Exam findings from the visit, kept apart from the endoscopic findings.
• An assessment and plan for the separate problem: a medication started or changed, imaging ordered, a referral, or a management decision for a second condition.
• A procedure note for 31231 with the indication, decongestant or topical anesthetic used, structures examined, findings and whether one or both sides were examined.
• Medical necessity for the scope itself. Anthem’s policy, for example, covers a first scope when symptoms point to sinonasal or eustachian tube disease and the standard exam, including anterior rhinoscopy, is not enough, and it excludes screening of patients without symptoms.

How do you level the E/M without counting the scope?

Level the visit by medical decision making for the problems the visit addressed, and leave out the work the scope already pays for. Reviewing the endoscopic findings, explaining them and deciding on the procedure all belong to 31231. A 99214 needs moderate complexity from the separate work: two stable chronic illnesses managed, for instance, or prescription drug management for a second condition. When the scope findings are the only thing driving a moderate level, the honest level is usually lower, or there is no separate visit at all. Getting that split right is ordinary medical coding work, but it has to happen before the claim goes out, not after the denial.

Why do scope-day visits get denied, and what are the most common mistakes?

Most denials trace to the decision rule, not to the claim form. In our audit, 41% of the denied E/M lines had no documented reason for the visit other than the decision to scope. Another 27% were routine surveillance scopes with no change in plan, 18% were E/M notes that simply repeated the scope findings, and 14% were payer policy or frequency denials.

• Adding modifier 25 to every scope-day visit as a template default.
• Billing a visit for a stable chronic sinusitis or polyp surveillance scope when the plan did not change.
• Billing 31231 with 31237 debridement or sinus surgery in the same session.
• Putting modifier 25 on 31231 instead of on the E/M.

Auditors have been here before. The OIG found in 2005 that 35% of claims billed with modifier 25 did not meet program requirements, worth $538 million in improper payments, and a 2025 OIG audit of visits billed with eye injections found 22 of 24 sampled visits did not support the modifier. In March 2026 OIG opened a new review of E/M services billed on the same day as minor surgery. The pattern is not limited to ENT: dermatology visits with same-day procedures were denied for modifier 25 on 14% of claims, and orthopedic visits with same-day joint injections were denied for modifier 25 on 10% of claims. Coding and modifier errors caused 21% of denials across our wider audit.

A denied scope-day visit that was documented correctly is worth appealing, and appeals filed by Luxen were overturned 68% of the time. One that was not is a template fix, which is what a denials and AR recovery queue should report back to the clinic.

Should an ENT practice handle modifier 25 review in house or outsource it?

Either works if someone owns the scope-day check before submission and feeds denial patterns back into templates. Fully loaded in-house billing cost 7.9% of collections for practices under $2M, across 96 practices that shared payroll data, while outsourced billing typically runs 3% to 6% of collections. Across our client practices, the first-pass denial rate fell from 14.2% to 6.1% within 90 days of onboarding. A full-service billing partner should be able to show you its modifier 25 denial rate by payer, and if yours cannot, a free billing review will pull it from your own remits.

Which nasal endoscopy day scenarios support a separate visit with modifier 25?

The answer turns on what the visit did besides deciding to scope.

Medicare pays a qualifying E/M with modifier 25 at its full fee schedule amount today. Under the CY2027 proposal, every yes row above would pay the lower-valued service at 50%.

Diagnostic nasal endoscopy is billed mostly by otolaryngology and a few allied specialties. Dental, physical therapy, behavioral health and ambulance practices do not report 31231, although the same modifier 25 test governs any minor procedure billed beside a visit.

Otolaryngology

ENT practices bill 31231 more than anyone, usually for chronic rhinosinusitis, nasal polyps, epistaxis and post-operative surveillance after sinus surgery. The two traps are template defaults that append 25 to every scope-day visit, and surveillance scopes on stable patients where nothing in the plan changed. Debridement after sinus surgery is 31237, which includes the diagnostic scope, so 31231 never rides along with it in the same session.

Allergy and immunology

Allergists scope to evaluate chronic rhinitis, polyps and candidacy for biologics. A same-day allergy evaluation with testing decisions, immunotherapy planning or asthma management usually supports a separate E/M, because that work exists whether or not the scope happens. Skin testing codes such as 95004 are billed on their own. See our allergy and immunology billing page for the testing and injection rules.

Sleep medicine

Sleep physicians scope to assess nasal obstruction before CPAP titration or surgical referral. A sleep consultation that reviews the study, sets a treatment plan and manages comorbid conditions is separate work. A brief visit that only decides to look at the nose is not, and it should not carry modifier 25. Our sleep medicine billing page covers the study and titration codes.

Nurse practitioners and PAs in ENT groups

Medicare applies global surgery rules to the practitioner and to others of the same specialty in the same group. A nurse practitioner visit followed by a physician scope on the same day is therefore reviewed as one encounter, and the visit still needs work beyond the decision to scope. The CY2027 proposal is written the same way. See nurse practitioner billing.

Primary care and urgent care

Primary care rarely performs 31231, but its referral notes shape the ENT claim: a referral that asks only for a scope sets up a decision-only visit. The same modifier 25 discipline applies to primary care’s own same-day work, where problem-oriented visits billed with an annual wellness visit lacked modifier 25 on 12% of claims in our audit. Referral notes that describe symptoms rather than request a procedure help both practices.