Otolaryngology Coding Alert

Question: Our four ENTs have a coding problem with outpatient surgery for a septoplasty (30520), turbinates (30140), and tonsillectomy and/or adenoidectomy. The physicians would like to know how to get paid 100 percent for the tonsil or adenoids even though the procedure is the third or fourth code we are billing. We tried modifier 59 with no success. Do you have any suggestions?

Oregon Subscriber

Answer: You would use modifier 59 (Distinct procedural service) to indicate a separate site if the insurers were bundling the code combinations. But multiple-procedure rules, not bundling edits, are causing your "problem."

Medicare carriers will reduce payment on additional procedures based on multiple-procedure rules. To account for the shared anesthesia and preparatory work involved in multiple surgeries, CMS pays subsequent procedures at 50 percent. Private payers also adopt this system.

With CMS you do not have to worry about how the carrier will apply the reduction. The carrier's system will automatically apply the reduction to the lower- priced procedures.

Payers- systems, however, may apply the reduction to any codes you report after line 1. Therefore, get in the habit of reporting procedures in descending value order with the code with the highest relative value units (RVUs) first. In addition, private payers may want you to append modifier 51 (Multiple procedures) to the subsequent procedures. For 2008, you could report your claim as follows: