Otolaryngology Coding Alert

Get paid for separate side FESS and separate session epistaxis -- and stay off payers' audit radar, by correctly using one of the most misused modifiers: 59 (Distinct procedural service).

The right combination of an otolaryngological procedure and a modifier can make or break your claim. "Every modifier tells a story," says Susan Ward, CPC, CPC-H, CPC-I, CPCD, CEMC, CPRC, coding and billing manager in Phoenix. Through modifiers, payers know what transpired in the operative process without having to read every operative report.

Modifier 59 indicates that a distinct procedure has been performed during the same date. This modifier encompasses treatment for multiple primary, unrelated problems and may represent a different surgery, a different site, a different lesion, a different injury, or a different area of injury.

Example: If the otolaryngologist performs a total ethmoidectomy (31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) on the right side and also a partial ethmoidectomy (31254, Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]) on the left, you would report the service as 31255 and 31254-59, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC,  president of New Jersey-based CRN Healthcare Solutions. Although total ethmoidectomy (31255) usually includes partial ethmoidectomy (31254), modifier 59 allows you to unbundle them when the physician does the total and then the partial on two different sites.

Example 2: The otolaryngologist performs a diagnostic nasal endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) in the office and later in the day sees the patient in the emergency room for complex epistaxis control (30903, Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method). You may append 59 to 30903 since you are reporting two different encounters for two procedures that are normally bundled together, says Cobuzzi.

You should use caution when using modifier 59 and check if another modifier isn't more appropriate. Usually dubbed as a "modifier of a last resort," modifier 59's descriptor indicates that you should only use it "if no more descriptive modifier is available, and the use of modifier59 best explains the circumstances." Anatomical (such as RT, Right side) or bilateral (50) modifiers, for instance, may be more appropriate to use than 59.

How to: Report the code without the modifier on the first line. On subsequent lines, report the code with modifier 59 and the unit of service is equal to one.

Why: You have to prove within the operative report that the otolaryngologist did a distinct procedure.

Reporting 59 on subsequent lines with a unit of one is the best way to explain this to the payer, Ward says. Just like any modifier, the risks in using or overusing modifier 59 come into play when you use it incorrectly. "As coders it is our responsibility to verify when procedures performed are bundled together in respect to Correct Coding Initiative (CCI) edits," adds Ward. "In not doing so and just appending modifier 59 to codes that we feel need it, we open ourselves and our practices to being 'red flagged' for a possible audit."

Wrong way: Some coders make the mistake of appending modifier 59 to a diagnostic laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic) when the physician is also performing a nasal endoscopy (31231). Even these procedures include different sites and different scopes, the two codes are intentionally bundled with these facts in mind, notes Cobuzzi. The only way you could unbundle these two codes with modifier 59 would be if the scope and bleed control occurred in different encounters during the same day, she adds.

Don't confuse modifier 59 with modifier 51 (Multiple procedures), which is used to identify secondary procedures or services provided along with the primary procedure. "I see modifier 51 as an indicator to payers that multiple procedures were done during one operative session," says Sylvia Thompson, CPC, billing supervisor of Rady Children's Hospital in San Diego. She gets to facilitate the issuance of reimbursement by  ndicating which of the multiple procedures is "primary." "Many payers allow for 100 percent of allowable for only the primary procedure and drop payment for subsequent procedures to 75, 50, or even 25 percent," she adds.

Meanwhile, modifier 59 is more of a "bundling/unbundling" modifier, which is "typically used to indicate that procedures normally considered 'components' of one another (therefore not separately reimbursable) are in certain cases to be looked at 'individually,'" Thompson says.

Vital: Always attach modifier 59 to the column 2 code, which is usually the lesser valued of the two services, or to the code -- regardless of value -- that would otherwise be denied or is a component of another, more comprehensive code.