Otolaryngology Coding Alert

But applying the appropriate modifier can prove elusive even to the most experienced otolaryngology coder. So, try your hand at four common otolaryngology examples to avoid appealing additional post-op procedures for incorrect appendages.

Suppose a patient needs a bilateral neck dissection. Due to the risk involved in the operation, the otolaryn-gologist first performs the RND (38724, Cervical lymphadenectomy [modified radical neck dissection]) on the right side, which has 90 global days. A week later, he performs the contralateral side (38724-LT [Left side]).

So, how is the second procedure related to the primary procedure's global period? In this scenario, the otolaryn-gologist planned to perform one portion of a procedure at one session and to complete the procedure at a later date, Horowitz says. Because the second resection (38724-LT) was planned at the time of the first resection (38724-RT), the second surgery is a staged procedure, he says. Therefore, you should report the second resection (38724-LT) and append modifier -58 (38724-58-LT).

When a surgeon removes a malignancy and the pathology report shows that the excision did not fully remove the growth, otolaryngology coders often wonder how to report the second procedure.

For instance, an otolaryngologist performs a total unilateral thyroid lobectomy to remove a nodule from a patient's thyroid lobe (60220, Total thyroid lobectomy, unilateral; with or without isthmusectomy), which has a 90-day global period. Although the surgery did not show definitive signs of malignancy, the pathology report returns with invasive follicular thyroid malignancy, which requires additional surgery. Therefore, the patient returns 14 days after the lobectomy for remaining thyroid tissue removal (60260, Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid).

In this case, the physician must perform a subsequent procedure. During the original surgery, the doctor did not know a malignancy existed, so he performed conservative treatment, removing less tissue. When the report showed a cancer diagnosis, the surgeon had to perform a more radical procedure. Consequently, you should assign 60260-58 to indicate that the patient needed a more extensive procedure, a thyroidectomy, because the primary operation did not adequately remove the malignancy, Horowitz says.

Secondary procedures also occur when postoperative bleeding requires treatment. Procedures such as tonsillectomy and septoplasty often result in hemorrhaging, which in some cases may require treatment in the operating room.

Consider a 6-year-old patient who has a tonsillectomy (42825, Tonsillectomy, primary or secondary; under age 12), which has 90 postoperative days. Five days after the surgery, the patient bleeds so profusely that the otolaryn-gologist has to control the oral hemorrhaging (42962, Control oropharyngeal hemorrhage, primary or secondary [e.g., post-tonsillectomy]; with secondary surgical intervention) in the operating room.

Although these procedures are related, they are not staged, Horowitz says. After the original procedure, a complication occurs that necessitates performing another service in the operating room, so you should append modifier -78 to the code for control of oral hemorrhage (42962-78).

Post Sinus/Septoplasty Patient Needs Debridement

During the 90-day global period of a septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft), which the physician performs at the same time as endoscopic sinus surgery, a patient returns to her otolaryn-gologist for sinus debridement (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]).

Because the sinus procedure contains zero postoperative days, without the septoplasty no global period would exist, making a modifier unnecessary for the debridement. In this case, the physician also performed a septoplasty, which creates a postoperative global package. Therefore, you have to ask, "How is the subsequent surgery - the debridement - related to the global period?" Ritter says. In this example, the debridement is unrelated to the procedure that triggered the global package - the septoplasty. Therefore, you should assign 31237-79, she says.