Otolaryngology Coding Alert

Question: I could use some help in correct coding and sequencing for sinus surgery. The physician did the following procedures: 30520, 31276-50, 30140-50, 31255-50, and 31267-50. My first question is whether I need to use either the 51 or 59 modifier. Also, according to our fee schedule, the septoplasty 30520 carries the higher fee. Should I sequence that first or do I bill a bilateral procedure first?

Connecticut Subscriber

Answer: Modifier 59 (Distinct procedural service) is not required on any of these codes because none of them are bundled assuming no other codes are going to be billed from the same encounter that would create any edit bundles. However, if you have a private payer who improperly bundles septoplasty procedures (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) with FESS (Functional Endoscopic Sinus Surgery), the 30520 may need a 59 modifier (Distinct procedural service) to indicate that the service was performed on a separate site from the sinus surgeries. But this is payer-edit driven and not standard coding convention. You would be modifying your coding because the private payer is not following the NCCI (National Correct Coding Initiative)

Modifier 51 (Multiple procedures) is no longer required for many payers, so your claim probably doesn’t necessarily need this modifier either. However, if you find that you have a payer that is reordering your procedures such that the highest paying procedure is not the first procedure and is receiving a multiple procedure reduction, you will find that you will need to use the 51 modifier to keep that payer from modifying your claims.

Additional FYI: The only reason you should apply modifier 59 to unbundle a bundled code pair is if you have special circumstances to unbundle, because the service is truly separate and distinct from the other procedure that is bundled to it. Ask yourself these questions:

• Was the procedure in question performed at a different encounter?
• Was the procedure in question performed by a different provider?
• Was the procedure in question performed on a totally different anatomic site (right only vs. left only for the other procedure, for example)?
• Was the procedure in question performed for a totally unusual overlapping reason that can be justified in the op note?

If the answer to those questions is “no,” coding with the 59 modifier may not be supported. Also remember that if the bundled codes were done bilaterally, in most situations modifier 59 will not be supported. You should never apply modifier 59 (or any other modifier) to simply bypass edits.

As for the order the procedures should go in, you have one of two guides that you can use. The first that you should look to is the specific payer’s fee schedule that you are following. If you have that payer’s fee schedule, attach what they will allow for each code, including multiplying the bilateral codes times 150 percent, and rank order the procedures from highest value to lowest value based on that payer’s fee schedule. That will tell you the order to put the procedures in.

If you do not have the payer’s fee schedule (which is found in many practices), use Medicare’s fee schedule. Do the same thing, applying the fees to each procedure (with 150 percent to the bilateral procedures) and rank order the procedures from highest fee to lowest and that will be the order you submit them on the claim.

If you do not have your payer’s fee schedule, reach out to your payer and get their fee schedule.  Not only do you need it to order your CPT^® codes on a claim, but more importantly, you need it to determine if you are being paid correctly when you receive your remittances.