Otolaryngology Coding Alert

To avoid denials for an E/M service on the same day as (or during the global period of) a procedure such as a laryngectomy, laryngoscopy, or parotid drainage, try this foolproof method for choosing between 24, 25, and 57. "Using the correct modifier can make all the difference regarding payment or denials by insurance companies," Claudia Stephens, CPC, billing manager for ENT for Children, PA, and president of the AAPC Richardson Chapter in Coppell, Texas.

Scenario: Suppose your ENT saw a patient for an E/M service in the office and is going to perform a related, major surgery that evening or the next day. What modifier should you attach to the E/M service?

Ask these questions to eliminate the bad choices and select the modifier that will provide the carrier with an accurate picture of the E/M service.

Answer: No, in the scenario above, the E/M service happens prior to the surgery. Therefore, you would not choose modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

You should only append modifier 24 to an appropriate E/M code when an E/M service occurs during a postoperative global period for reasons unrelated to the original procedure. Modifier 24 tells the payer that the surgeon is seeing the patient for a new problem. Therefore, the plan should not include the E/M service in the previous procedure's global surgical package.

In other words, "if your ENT sees a patient during her 30 day post-op tonsillectomy for ear pain, then you should  use modifier 24," Stephens says.

Rule: You cannot bill separately for E/M-related services [relating to the original surgery] during the global period, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, consulting manager for Pershing, Yoakley, and Associates in Clearwater, Fla. The global surgical package includes routine postoperative care during the global period.

Example: A patient undergoes laryngectomy (31365, Laryngectomy; total, with radical neck dissection) for cancer of the larynx (161.9, Malignant neoplasm of larynx, unspecified). Laryngectomy is a major procedure, with a 90-day global period.

Several weeks later, the patient returns to the ENT with a new problem (for instance, 388.70, Otalgia, unspecified; earache NOS). The physician performs an evaluation for this new, distinct problem. In this case, you should append modifier 24 to the correct E/M code (for example, 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) with a diagnosis of 388.70.

Answer: Major. Because the surgery was a major service, then you should strike off modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) as an option. Reserve modifier 25 for when the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with zero-day, 10-day, or possibly "XXX" global periods (depending on the perspective of the payer), says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga. Make sure the service and the documentation supports the E/M as a significant, separately identifiable service.

Example: The ENT sees a new patient on consult from a primary-care physician. The patient is complaining of recurrent cough and dysphasia, as well as a "feeling of lump in the throat." (ENTs will sometimes describe this condition as globus, 784.9, Other symptoms involving head and neck. Do not confuse this with globus hystericus, 300.11, which is a psychiatric disorder.)

After conducting a history and exam, the ENT decides to perform a laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic). The exam reveals a mass in the larynx (for example, 784.2, Swelling, mass, or lump in head and neck). He records these findings in a separate note. In this case, because documentation supports billing for a separate E/M service, you may report both the E/M service (for example, 99243, Office consultation for a new or established patient ...) and the laryngoscopy (31575).

Because 31575 includes a 0-day global period, you should append modifier 25 -- rather than modifier 57 -- to the E/M code. "You would add modifier 25 to the E/M code to identify the evaluation as a separately identifiable service from the procedure performed during the course of the exam," Stephens says.

Answer: Yes. In the beginning scenario, the surgery is "major" and "related" to the E/M service the physician performs the  day of or the day prior to the surgery. Therefore, you should append modifier 57 (Decision for surgery) to your E/M service (such as 99214, Office or other outpatient visit ...) to indicate that this E/M service led to the decision for surgery.

Caution: Failure to append modifier 57 to the E/M code will result in the payer bundling the E/M service into the global surgical package, leading to a loss in reimbursement. Without the modifier, the visit will appear to be the preoperative visit that the global surgical package includes.

Example: Two days after an otolaryngologist admits a patient with parotitis to the hospital, the patient develops a parotid abscess that requires complicated draining.

In this case, you should report both the parotid drainage (42305, Drainage of abscess; parotid, complicated) and the appropriate-level hospital visit (for example, 99232, Subsequent hospital care, per day, for the evaluation and management of a patient ...). The parotid drainage's 90-day global procedure includes all E/M services the day of and the day before the procedure. Therefore, you should append modifier 57 to 99232 to indicate that this E/M service led to the decision for surgery.

Tip: Relax -- if you haven't been using the correct E/M appendage, all is not lost. Many Medicare carriers have a dedicated review line that you can call to add the missing modifier, and payment is usually processed between 10 and 14 days.