Does 31238 require prior authorization?

No, 31238 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 31238?

Medicare facility rate: $144.29. Non-facility rate: $260.19. Work RVU: 2.67.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

2.67

Facility

$144.29

Non-Facility

$260.19

Documentation showing persistent symptoms despite medical management (evidence of failed medical therapy/prior medical management)
Documentation of CRS duration (CRS lasts longer than 12 weeks) when applicable
Please refer to CMS Medicare Coverage Database for the most current applicable CMS National Coverage Determination (NCD)/Local Coverage Determination (LCD)/Local Coverage Article (LCA).
Refer to CMS website for the most current applicable CMS Online Manual System (IOMs) and Transmittals.

Sinus conditions that indicate a need for sinus surgery include acute, subacute or chronic rhinosinusitis (CRS)
other pathologies involving the sinuses
skull base defects
CRS, both allergic and nonallergic, is the most common indication for functional endoscopic sinus surgery (FESS)
CRS lasts longer than 12 weeks
CRS presents with one or more of the following symptoms: cough, headaches, nasal congestion, postnasal drainage, rhinorrhea and sneezing

HUMANA-MINIMALLY-INVASIVE-SINUS-AND-EUSTACHIAN-TUBE-PROCEDURES-MA — Minimally Invasive Sinus and Eustachian Tube Procedures - Medicare Advantage

Ask Verity about documentation requirements, denial risks, or coverage in your state.