Otolaryngology Coding Alert

Question: A patient who is returning for follow-up after unilateral endoscopic total ethmoidectomy and maxillary antrostomy complains of a sore throat. The otolaryngologist evaluates and manages the problem and also performs endoscopic sinus debridement on the patient. How should I report the encounter?


Illinois Subscriber


Answer: You should code both the office visit and the debridement. Normally, you would report only the debridement (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). 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 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Separate ICD-9 codes solidify your claim for an office visit in addition to debridement. You should link the sore throat diagnosis, such as acute pharyngitis (462), to the E/M code. This will tell the insurer that the otolaryngologist evaluated and managed a new problem.

For the debridement, use the appropriate sinus surgery diagnoses, for instance, chronic ethmoidal sinusitis (473.2) and chronic maxillary sinusitis (473.0).

Remember: You don't need a global surgery modifier on the E/M code or on the debridement code. Both 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) and 31256 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy) contain zero global days. Therefore, no global surgical package exists at the follow-up encounter, which makes modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) or 79 (Unrelated procedure or service by the same physician during the postoperative period) unnecessary. 

Answers to You Be the Coder and Reader Questions reviewed by Barbara J. Cobuzzi, president of CRN Healthcare Solutions in Shrewsbury, N.J.; and Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor.