Otolaryngology Coding Alert

Hint: Assign 57, not 25, for E/M prior to major surgical procedure.

Your surgeon performs an E/M service on the same date as a procedure, so you reach for modifier 25, right? Not so fast. Ask yourself two questions first.

Question 1: Does the E/M Follow Another Service?

When an E/M service occurs during a postoperative global period, but for reasons unrelated to the original procedure, you should append modifier 24 (Unrelated E/M service by the same physician during a postoperative period) to the appropriate E/M code. By appending modifier 24, you make the payer aware that the surgeon is seeing the patient for a new problem, and therefore the payer should not include the E/M in the global surgical package of the previous procedure, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

Remember: You cannot bill separately for related services during the global period. According to AMA CPT, surgery includes routine postoperative care during the global period in the global surgical package. Keep in mind that Medicare includes more than routine postoperative care in the global period. Medicare includes all services unless the patient requires a return to the operating room.

Example: A patient undergoes laryngectomy (31365, Laryngectomy; total, with radical neck dissection) for cancer of the larynx (161.9, Primary malignant neoplasm of the larynx [not elsewhere classified]). 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.

ICD-10: When you make this shift to from ICD-9 to ICD-10, your malignant neoplasm of the larynx will expand into six options (C32.-), depending on the anatomical location. As for your otalgia diagnoses (388.70), you will have four options (H92.0-) based on if this condition occurs in the right ear, left ear, both ears, or unspecified.

Learn more: For additional information on modifier 24, see "Call on 24 for Complication Evaluations--Maybe" later in this issue.

Question 2: 'Major' or 'Minor' Procedure?

When the surgeon decides to perform a procedure during an E/M service and provides the procedure on the same day (or, for major procedures, the same day or the next day), you can bill the E/M service separately. Depending on the length of the global period associated with the procedure, you should append either modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) or modifier 57 (Decision for surgery) to the appropriate E/M code.

Minor procedures mean 25: If the surgeon provides a significant, separately identifiable E/M service on the same date as a minor procedure, including those with 0-day, 10-day or "XXX" global periods, you should append modifier 25 to the E/M code, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

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 "lump in the throat." (ENTs will sometimes describe this condition as globus, 784.9x, 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 conduct a laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic) because he could not get adequate visualization via the mirror exam (indirect laryngoscopy) as indicated in the E/M note. 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, 99244, 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.

ICD-10: Code 784.2 expands into R22.0 (Localized swelling, mass and lump, head) or R22.1 (Localized swelling, mass and lump, neck).

Remember, the globus hystericus (300.11) diagnosis is a psychiatric disorder. The ICD-10 equivalents are F44.4 (Conversion disorder with motor symptom or deficit) or F44.6 (Conversion disorder with sensory symptom or deficit).

90-Day Global = Modifier 57

When the surgeon decides to perform major surgery (that is, a surgery with a 90-day global period that has not already been scheduled) and provides the surgery that day or the next day, you should append modifier 57 to the E/M code, according to Medicare guidelines outlined in the Medicare Carriers Manual (section 15501.1).

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 a preoperative E/M service. Therefore, you should append modifier 57 to 99232 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 into the global surgical package for 42305, leading to a loss in deserved reimbursement.