Otolaryngology Coding Alert

Question: We have a patient present with chronic hypertrophy of the turbinates who was scheduled for an inferior turbinate radiofrequency ablation (RFA) procedure. The provider numbed the patient and began to ablate the right sided turbinate, but the patient complained of severe pain. The provider then stopped, applied an additional round of numbing agent, and began again 15 minutes later. The patient continued to complain of pain, at which point the provider terminated the procedure. Is there enough here to bill out using an RT modifier?

Mississippi Subscriber

Answer: CPT^® code 30802 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural [ie, submucosal]) is inherently unilateral or bilateral. Typically, if the provider completes the operation on one side of the nose, you can apply the respective LT (Left side) or RT (Right side) modifier. However, if the provider performs the procedure bilaterally, you will not include a modifier 50 (Bilateral procedure).

In this example, there is not enough information available to determine whether or not the provider performed a complete turbinate RFA on the right side before terminating the procedure. If the documentation supports a completed right-sided procedure, and the surgeon agrees, then you may bill out as 30802-RT. However, if the provider terminated the procedure prior to achieving full turbinate reduction of the right inferior turbinate, you should also include modifier 52 (Reduced Services) in addition to RT. Modifier 53 (Discontinued procedure) can only be used if the procedure was discontinued for the well being of the patient after the induction of anesthesia. Patient complaints of pain is not considered an acceptable reason for use of modifier 53.

In addition to submitting the claim electronically (to prove timely submission), you are advised to submit the claim on paper to properly identify the extent of work the provider performed before terminating the procedure. It is recommended that the paper copy of the claim include the statement: “Documentation copy of a claim already submitted electronically, not a duplicate claim.”