Otolaryngology Coding Alert

Question: My otolaryngologist performed a bilateral endoscopic anterior ethmoidectomy (31254-50), bilateral inferior turbinate resection (30130-50) and right endoscopic maxillary antrostomy with tissue removal (31267-RT) and left endoscopic maxillary antrostomy (31256-LT). The insurance company denied 31256-LT as a component of 31267-RT. Should I refile the claim?

Maine Subscriber

Answer: You should resubmit the claim using modifier -59 (Distinct procedural service).

When the otolaryngologist performs maxillary antrostomy and maxillary antrostomy with tissue removal on the same side, CPT makes 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) a component of 31267 (... with removal of tissue from maxillary sinus). Thus, the insurer probably set up its system to reject claims containing both codes.

To override the edit, you should append modifier -59 to 31256. This modifier informs the payer that the surgeon performed 31256 on a different side than 31267.

Although left (modifier -LT) and right side modifiers (modifier -RT) indicate body sides, not all insurers recognize them. Using the payment modifier -59 is your best bet in the absence of specific payer requirements to the contrary.