Otolaryngology Coding Alert

Use this argument to avoid and fight 31237 denials

Your payer just denied payment for 31237 performed after you filed a claim containing 30520, 30130 and 31254 for the same patient. Accept the denial? No, you can appeal -- if you used modifier -79 on 31237.

Not using the right postoperative modifier to indicate how the debridement is related to the primary surgery will trigger a rejection of 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [surgical procedure]). But, with an initial claim for multiple nasal procedures, you may have a hard time determining which operation the postoperative procedure relates to. You can get to the proper modifier and add ammunition to your appeals if you follow these two steps:

1. Focus on Breaking Septo/Turb Global

You should first determine the postoperative global period that the original surgery created. An operation that includes a septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), turbinectomy (30130, Excision turbinate, partial or complete, any method) and partial ethmoidectomy (31254, Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) triggers two surgical periods. Both the nasal septum repair (30520) and the turbinate bone removal (30130) contain 90 global days. But, the ethmoid sinus revision (31254) contains zero global days.

Rule: You use postoperative modifiers, modifier -58 (Staged or related procedure or service by the same physician during the postoperative period), -78 (Return to the operating room for a related procedure during the postoperative period) and -79 (Unrelated procedure or service by the same physician during the postoperative period), to break the original procedure(s)' global period(s). To decide which modifier to use, ask "How is the subsequent procedure related to the postoperative period?" says Tara R. Ritter, appeals coordinator for American Physician Services, which serves multiple ENT, allergy, sinus and head and neck practices in Atlanta.

In the above sinus-debridement scenario, 31237 is unrelated to either 30520's or 30130's global period. "Modifier -79 is appropriate because the otolaryngologist debrides the crusting and anything else that is in the sinus cavity following the functional endoscopic sinus surgery (FESS)," says Chrissy Letsen, CPC, billing coordinator at Metropolitan ENT, with four otolaryngologists in Alexandria, Va.

Translation: The debridement follows the ethmoidectomy, which contains no postoperative period. So if the otolaryngologist performs only an ethmoid-ectomy (31254), you wouldn't need a modifier to bill the subsequent debridement (31237). No global period would exist, making a postoperative modifier unnecessary.

2. Fight Appeals Using an Unrelated Argument

If you report 31237-79 with a 30520, 30130 and 31254 claim and the payer denies the debridement, you should appeal the bundle. Inform the insurer that the debridement is not related to either the nasal septum repair (30520) or the turbinate bone removal's surgical period (30130).

Beware: Some payers have implemented edits that automatically reject 31237 during a septoplasty's global period. For instance, Anthem Blue Cross Blue Shield in Virginia is not paying for 31237. The insurer bases the bundle on the incorrect argument that the debridement is related to the septoplasty, Letsen says. "But, the otolaryngologist doesn't debride the septum."

Action: If any of your insurers adopts BCBS's policy, use documentation to show the payer that the debridement is unrelated to the septoplasty. Have your otolaryngologists write a clinical letter explaining why the debridement relates to the sinus surgery and not to the septoplasty, Letsen says. Include medical information supporting this argument from the Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) available at www.entlink.net/practice/products/indicators/debridement.html.

You should also write a cover letter stating that the National Correct Coding Initiative doesn't bundle 31237 with 30520. And, Medicare didn't include debridement in the sinus surgery's relative value units. Thus, the debridements are billable, Letsen says.

Take the fight to another level. Involve your medical society, the department of insurance, and your state's insurance commissioner to make sure you're paid appropriately and do not have to refund money.