Otolaryngology Coding Alert

Question: A patient who is returning for follow-up after unilateral endoscopic maxillary antrostomy with tissue removal and turbinectomy complains of a cough and fever. The otolaryngologist evaluates and manages the problem and also performs endoscopic sinus debridement on the patient. What modifiers do I need to report the encounter?

Kentucky Subscriber

Answer: Because the unrelated office visit and a staged debridement (planned staging for the endoscopic maxillary antrostomy) occurred during the turbinectomy's 90-day global period, you will need to use modifiers 24 (Unrelated evaluation and management service by the same physician during a postoperative period) with the EM service and modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) with the debridement. To indicate the E/M is a significant and separate service from the debridement, you will also use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Normally, you would not charge an E/M service that occurs within an active postoperative period. But because the otolaryngologist performs the E/M service for a problem that is unrelated to the turbinectomy you should bill the office visit appended with modifier 24.

You should also use modifier 58 with the debridement code (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). Modifier 58 indicates that the otolaryngologist performs a procedure -- debridement -- that is a planned staged procedure related to the therapy and healing to achieve the desired outcomes from the maxillary antrostomy.

The scenario's same-day service and procedure necessitate modifier 25 because 31237 is a minor procedure, which has a built in mini EM service. You would normally include a minor related E/M service with the debridement. But because the otolaryngologist in your example performs a significant and separate service from the debridement, you should also report the office visit (9921X, Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier 25.

Confusion avoided: Even though the patient requires debridement due to sinus surgery, the antrostomy does not make global surgery modifiers necessary. Functional endoscopic sinus surgery (FESS) codes including 31267 contain zero global days. As soon as a non zero global day surgery (such as 90 days) is performed with the zero global day FESS surgery, that entire surgical encounter gets the longer global attached to it for the entire time the longer global exists (such as the full 90 days).

Your ICD-9 coding should demonstrate the office visit's separate nature from the debridement and the turbinectomy. Different diagnoses will tell the insurer that the otolaryngologist evaluated and managed a significant and separate problem from the day's procedure (31237) and that the problem is unrelated to the active postoperative period created by the turbinectomy. The debridement also should only have the maxillary sinusitis (473.0) associated with it, as it is staged to the 31267 and unrelated to the the turbinectomy.

Here's how: You should link the definitive acute diagnosis, such as upper respiratory infection (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site), to the E/M code. For the debridement, use the appropriate sinus surgery diagnoses, such as chronic maxillary sinusitis (473.0).

The claim could read:

   CPT codes                               ICD-9 codes

  9921X-24-25                              465.9

   31237-58                                   473.0

ICD-10: When your diagnosis coding system changes in 2013, you will use J32.0 (Chronic maxillary sinusitis) instead of 473.0. Instead of 465.9, you'll report J06.9 (Acute upper respiratory infection, unspecified).