Otolaryngology Coding Alert

In many cases, you can collect for the multiple procedures

Myth: Reporting postoperative endoscopic debridement will lead to denials and accusations of incorrect coding, so you should avoid using 31237 when your otolaryngologist performs a surgery that has more than a zero day global along with FESS surgery such as a septoplasty or a turbinectomy.

Reality: You can report the debridement, the septoplasty, the turbinectomy, and the FESS -- if you know which modifiers to use, and which diagnoses are the most accurate.

Determine Which Surgery the ENT Initially Performed

An otolaryngologist may perform postoperative debridements (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) for sinusitis after functional endoscopic sinus surgery (FESS, 31254-31294), which may also include septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) and/or turbinectomy (30130, Excision inferior turbinate, partial or complete, any method, or either 30130, Excision inferior turbinate, partial or complete, any method, or 30140, Submucous  esection inferior turbinate, partial or complete, any method). Before you can determine whether you should report the post operative debridement, you must first identify the primary surgery.

Why: The Medicare Physician Fee Schedule assigns different global periods to 30520, 30130-30140 and FESS codes. According to the 2010 fee schedule, codes 30520 and 30130-30140 have 90-day global periods, but FESS codes contain zero global days (except 31290-31294 which have 10 days global period). Different global periods may equate to two coding scenarios.

Scenario 1: The otolaryngologist performs debridement after sinus surgery. Because FESS codes have zero global days, you can bill the debridement after endoscopic sinus surgery with 31237. Because the physician performed no major surgeries, you don't need a modifier.

Note that 31237 is a unilateral code and as such, if the physician should perform the debridement on both sides, you would append modifier 50 (Bilateral procedure).

Scenario 2: Your otolaryngologist performs a debridement of the sinuses within 90 days after septoplasty and/or turbinectomy with or without FESS. In this case, the debridement falls within 30520's and/or 30130-30140's global surgical periods.

Billing the debridement hinges on the answer to another question.

Why Did the ENT Perform Debridement?

Next, you need to focus on what the physician is debriding and why after performing a septoplasty and/or turbinectomy with or without FESS.

In black and white: Although many insurers are hesitant to print their policies for these procedures in writing, you can find documentation from some payers. For instance, the August 2004 CareFirst Blue Cross/Blue Shield newsletter notes, "Procedure 31237 will be reimbursed separately when performed as postoperative care following FESS procedures which have a zero (0) day global period or after a ten (10) day global period. Endoscopic surgical sinus cavity debridement is not reimbursed separately when performed as a postoperative treatment related to major surgeries (e.g., septoplasty) within a 90-day global period."

Unrelated to septo/turb: Since the otolaryngologist performs sinus debridement for a reason that is unrelated to why she worked on the septum and/or turbinates, you should bill for the debridement, but you'll need to append a modifier. The surgeon must document this in his chart, so that you have the material to appeal any denials and show the payer that the debridement was not for the global procedures but for the zero day sinus procedures.

Although some practices append modifier 58 (Staged or related procedure or service by the same physician during the postoperative period), most coding experts agree that a better choice is to append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 31237 to indicate that the debridement is unrelated to the postoperative period created by the septoplasty and/or turbinectomy, says Laura Carbonaro, director of central billing operations with ENT and Allergy Associates, LLP, with offices in New York and New Jersey.

"If you don't attach the 79 modifier, the payers' claims adjudication software will most likely reject the debridement as inclusive," Carbonaro says. "If there are other modifiers on the debridement, make sure the 79 is in the first position so your claim doesn't get summarily denied against an unrelated global. Also, be certain that the diagnosis codes used for the debridement are related to the FESS."

For instance, you might report post-op FESS-related debridement with 31237-79 using the diagnosis code 473.0 (Chronic maxillary sinusitis)

Modifier advice in black and white: The August 2004 CareFirst Blue Cross/Blue Shield newsletter notes, "When the patient is being followed postoperatively for both a 0/10 day global AND a major (90-day global) procedure, append modifier 79 to 31237 to indicate that the debridement is unrelated to the major procedure ... Please note that the nasal surgery codes are considered unilateral. Append modifier 50 as appropriate when a procedure is performed bilaterally."

Documentation should reflect the fact that the debridement is unrelated to the reason that the otolaryngologist worked on the septum and or turbinates, and it should show medical necessity for the debridement.

Example: After a septoplasty for a deviated septum, a turbinectomy for hypertrophy, a total ethmoidectomy (31255, Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) for chronic ethmoidal sinusitis (473.2) and a maxillary antrostomy (31256, Nasal/sinus endoscopy, surgical, with maxillary antrostomy) for chronic maxillary sinusitis (473.0), an otolaryngologist performs debridement.

Documentation indicates the debridement was to remove the crusting that occurs following sinus surgery, to prevent infection and to keep the airway patent.

Because the ENT performs the debridement for a reason (chronic ethmoidal and maxillary sinusitis) that is unrelated to the reason for the septoplasty and/or turbinectomy, you should report the debridement with modifier 79 if either the physician did the septoplasty or the turbinectomy within the original service. Append modifier 50 also if the physician did the debridement bilaterally.