Otolaryngology Coding Alert

Overuse of modifier -59 (Distinct procedural service) raises red flags and invites audits. But, knowing some typical otolaryngology scenarios in which to use it will steer you to the path of reimbursement success.

When an otolaryngologist controls nasal bleeding at a separate, operative session - a procedure that is usually bundled - it may warrant individual billing with modifier -59 on the lower-valued code.

For instance, suppose a patient who has a nosebleed presents to his otolaryngologist at 8 a.m. The physician uses a scope to control the bleeding. At 2:30 p.m., he returns due to another nasal hemorrhage, which the otolaryngologist controls with packing. Report 31238, 30903-59.

For the first encounter, the otolaryngologist bills the scope control-of-bleeding code 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage). For the afternoon visit, the doctor assigns packing of epistaxis code 30903* (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).

The Correct Coding Initiative (CCI) bundles 30903 with 31238. However, the situation meets the definition of modifier -59. These procedures are 1) separate and distinct, 2) not usually performed together, and 3) performed at different operative sessions. You should report both the scope (31238) and the packing (30903) appended with modifier -59 to indicate a different operative session. "

Append modifier -59 to the lower relative value unit (RVU) procedure, no matter what was done second," says  Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryn-gology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. The scope (31238) is a higher-valued procedure (7.24 RVUs) than the packing (30903, 4.86 RVUs). So, append modifier -59 to 30903.

If the procedures are reversed and the otolaryngologist packs the epistaxis first and uses the scope in the afternoon, the coding remains the same.

"Documentation is king," Cobuzzi says. It's easy to show that different operative sessions occurred when the place of service is different. But, when the procedures take place at the same location, documentation must clearly reflect that a separate, operative session occurred. A note stating "The patient has returned with a nosebleed" makes it clear that two sessions exist, Cobuzzi explains. 

 When an otolaryngologist performs sinus surgery on different sides on the same day, the procedures are separately reportable. Consider an otolaryngologist who performs a partial ethmoidectomy on a patient's left side and a total ethmoidectomy on the right side. Assign 31255, 31254-59.

For the partial ethmoidectomy, the surgeon reports 31254-LT (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]; Left side). For the total ethmoidectomy, she uses 31255-RT (& with ethmoid-ectomy, total [anterior and posterior]; Right side). CCI bundles 31254 into 31255. Normally, you would report either part of the total or the total.

"That's true on the same site." Cobuzzi says. But when the procedures are performed on different sides, the left and right are a significant, separate procedure, which deserves individual reimbursement, she explains.

Therefore, you should bill both procedures. The partial ethmoidectomy is valued less than the total procedure, so append modifier -59 to 31254. The coding would appear as 31255-RT, 31254-59-LT. Although many carriers do not process -LT and -RT, they are very helpful from an informational standpoint.

Turbinectomy, Ethmoidectomy Are on Different Sites

 When an otolaryngologist performs a turbinectomy with an ethmoidectomy, carriers often bundle the procedures. "However, if documentation shows that the surgeries occurred on different sites, you may report both operations," says John Lavere, MBA, CPC, director of compliance for Charlotte Eye Ear Nose & Throat Associates in North Carolina. For instance, an otolaryn-gologist resects the middle turbinate on the patient's left side to remove an airway obstruction and does a total right ethmoidectomy. Assign 31255, 30130-59.

For the excision of the turbinate, the physician assigns 30130 (Excision turbinate, partial or complete, any method). For the functional endoscopic sinus surgery (FESS), the doctor reports 31255. Because the operations are performed on different sites, he reports the turbinectomy (30130) and the endoscopic ethmoidectomy (31255), and appends modifier -59 to 30130 to indicate a separate site.

Many private payers erroneously bundle inferior turbinectomies with ethmoidectomies, assuming that the excision of the turbinates is incidental to the sinus surgery. Although this may be true for FESS with middle turbinates, it's not the case with inferior turbinates, Cobuzzi says. Therefore, another application is to append modifier -59 to 30130 for the inferior turbinate to indicate that the procedure occurred on another site from the middle turbinate, which is normally considered incidental.

When assigning modifier -59, make sure the second procedure is not a staged procedure. For instance, suppose an otolaryngologist biopsies a neck mass for frozen section. The malignant report comes back the same day, and the doctor performs a modified radical neck dissection during the same operative session.

For the initial biopsy, the surgeon reports 38510 (Biopsy or excision of lymph node[s]; open, deep cervical node[s]). For the neck surgery, he assigns 38724 (Cervical lymphadenectomy [modified radical neck dissection]). He appends modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to the lower-valued procedure, which is 38510. In this case, assign 38724, 38510-58.

Although you make think modifier -59 is appropriate to indicate a separate procedure, modifier -59 is also the modifier of last resort. "When another already established modifier is appropriate it should be used rather that modifier -59," CPT states. "Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used."

"According to coding rules, the procedures should be paid on the multiple procedure fee reduction schedule or in full based on the procedure code," Lavere says. "Medicare and private payers will vary based on their multiple fee schedule reduction formula. Additionally, some payers either don't recognize or disregard modifier -59. Thus, it is key to follow up on your evaluation of benefits to ensure proper reimbursement." Make sure to file the full fee and allow the carrier to determine the adjustment.

"The operative notes should always clearly indicate the separate/distinct procedure," Lavere says. "This will help in the appeals process." If you notice a trend of initial denials, call the appropriate carrier's medical director for guidance. Most of the time, dropping the claims to paper to be submitted with supporting documentation is sufficient in reversing a denial.