Otolaryngology Coding Alert

Question: The physician performed a modified radical neck dissection (38724) in addition to a radical resection of a neck tumor (21558). Can these two procedures bill together, or is one included in the other?

Kentucky Subscriber

Answer: The answer to this question depends on how these procedures are documented. A Correct Coding Initiative (CCI) edit shows that 38724 (Cervical lymphadenectomy [modified radical neck dissection]) is mutually exclusive to 21558 (Radical resection of tumor [e.g., sarcoma], soft tissue of neck or anterior thorax; 5 cm or greater), which means it cannot be coded in addition to 21558. However, the CCI edit allows for the use of an overriding modifier (59, Distinct procedural service) if the documentation supports the use of the 59 modifier (or for Medicare, the -X{EPSU} modifiers).

An example of when the 59 modifier (or the Medicare “X” modifier) would apply is if the physician excises the neck tumor on one side of the neck and performs the modified radical neck dissection (MRND) on the other side of the neck. In this example, you may apply the following codes for a non-Medicare payer:

38724-59-RT (Right side)
21558-LT (Left side)

For a Part B Medicare payer, the same services would be:

38724-XS (Separate structure)-RT
21558-LT

You will apply the 59 modifier or XS modifier to 38724 because the MRND is a column 2 code for the radical resection of the neck tumor. Always apply the overriding bundle modifiers to the column 2 code — or the mutually exclusive code — which is not always the lower relative value unit (RVU) code (as seen in this example). The 59 and XS modifiers are supported because the physician performed the MRND on a different site or structure from the resection of the neck tumor.

Keep in mind: If the documentation does not warrant the use of an overriding modifier, compare the fee schedules of both procedures when making a decision on which to use. In this case, 38724 would actually be the code with the higher total (RVUs); 41.83 as compared to 38.80 for 21558.