Otolaryngology Coding Alert

Question: I submitted a claim for 31267 and 61782 using the same diagnosis. The insurance paid for 31267, but denied 61782 as 'inclusive.' I was told I should resubmit with a modifier. Is modifier 59 appropriate?

Illinois Subscriber

Answer: No. Do not apply modifier 59 because it is not a separate site or separate encounter. FYI, 61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure]) is an add-on code, which means it belongs with 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus).Use the policy on the American Academy of Otolaryngology -- Head and Neck Surgery web site at http://www.entnet.org/Practice/policyIntraOperativeSurgery.cfm, and fight for payment. No modifiers should be needed when 61782 is used unless the private payer has their own policy on modifiers for add on codes. If the private payer does have their own policy, get that policy in writing.

Important: Make sure you have good documentation for medical necessity and the use of the stereotactic guidance is adequately documented, because now, in the appeal process, you are going to have your documentation under a microscope. You always need medical necessity and demonstration of the use of stereotactic guidance whether the op note is going to be reviewed.

If you are having continued problems getting +61782 paid with medically necessary sinus surgeries, contact the Practice Management Department of the American Academy of Otolaryngology/Head and Neck Surgery and notify them with copies of the remittance advices so that they can address this problem as an Academy.