Otolaryngology Coding Alert

Question: We had a patient return two days following an inferior turbinate ablation surgery with complaints of a chronic sore throat due to the numbing agent administered prior to the surgery. What diagnosis code should I report, and may I bill this out as an evaluation and management (E/M) visit?

Arizona Subscriber

Answer: First, you want to determine the global period of code 30802 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal)). Since the global period is 10 days, if the patient is a Medicare patient, you’ll want to refer back to the following guidelines found in the CMS Global Surgery Booklet. CMS lists the following services, among others, as included in the global surgery package:

• All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications, which do not require additional trips to the operating room.
• Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery.

The only way in which treatment of a postoperative complication is billable inside the global period is if the complication is severe enough to warrant a return to the operating room (OR). Where this question becomes infinitely trickier is when you might consider what does and does not constitute a surgical complication. You could certainly make a case that, since the area affected (throat) is unrelated to the surgical site, the follow-up visit to treat the sore throat should not be considered a complication at all.

However, if the adverse reaction on the throat is actually the result of the numbing agent, it’s safe to assume that the payer will consider the follow-up consultation visit related to the underlying surgical procedure. Keep in mind that in order to receive reimbursement for the follow up visit, you would have to apply modifier 79 (Unrelated Procedure or Service by the Same Physician or other qualified health care professional During the Postoperative Period). Despite the fact that you don’t have a firm definition as to what qualifies as a complication, you’d be inappropriately appending modifier 79 due to the “unrelated” modifier designation.

As for the diagnosis code, you will refer to the Table of Drugs rather than the ICD-10-CM index. Here, you will look up Anesthesia ⇒ local ⇒ adverse effect which leads you to T41.3X5A (Adverse effect of local anesthetics, initial encounter).