Otolaryngology Coding Alert

Question: We’ve got a payer denying 30901-RT when submitted with a 99204-25. Is there any clear reason why the payer might deny this claim?

Florida Subscriber

Answer: Modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) indicates to the payer that 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive ...) is separate from 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method). Without seeing the remittance form, it’s hard to know why the payer denied the claim, but the answer may have to do with the payer’s guidelines on the use of laterality modifiers for 30901. If the payer doesn’t allow the use of RT (Right Side) and LT (Left Side) modifiers on 30901, then you’ll want to resubmit without the RT modifier.

Consider: Another reason for the denial may be because the payer does not bundle new patient visits with minor procedures. Therefore, it would not require modifier 25 with the E/M service. You may want to check your payer’s guidelines to see if it treats new patient visits the same as established patient visits. You may also consider a scenario in which the payer requires two separate diagnoses to distinguish between respective services.