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?

South Carolina Subscriber

Answer: No. Do not apply modifier 59 (Distinct procedural service) 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). Because 61782 is an add-on code, you also would not use modifier 51 (Multiple procedure).

Use the policy on the American Academy of Otolaryngology -- Head and Neck Surgery web site (URL: www.entnet.org/Practice/policyIntraOperativeSurgery.cfm), and fight for payment. You don't need any modifiers when using 61782 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.