Otolaryngology Coding Alert

Question: We are being denied payment on 31231 as being included in 90-day post op care. The original procedures performed were 30520, 30140, 31255, and 31267. We billed with modifier 79 and 473.0 diagnosis, but Highmark Blue Shield denied us even after appeal. I called Highmark Blue Shield and was told that the denial came from the Physician Advisory Board and this is the highest level of appeal. My initial appeal stated that the sinus surgery does not hold a global surgery period and that modifier 79 modifier indicated the 31231 was unrelated to the original procedures. How can I get this claim paid?

Pennsylvania Subscriber

Answer: It does seem that Highmark is ignoring modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). Perhaps your practice should contact your state medical and  otolaryngology societies. Your physician could request a meeting with Highmark's medical director, as well. It's true that the original septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) and turbinate resection (30140, Submucous resection inferior turbinate, partial or complete, any method) do have a 90-day global period, so your use of modifier 79 is appropriate. Presumably, those procedures were performed with a different diagnosis than 470 (Deviated nasal septum) to demonstrate that the scope was unrelated to the cause for the 90-day global.

FESS procedures like 31255 (Nasal/sinus endoscopy, surgical; with ethmoidectomy, total [anterior and posterior]) and 31267 (Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) have zero global days and shouldn't affect 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]).

You got it right: Since the diagnostic scope is related to the endoscopic sinus surgery and not the septum repair, modifier 79 indicates that it is a payable service. You need to fight, appeal, have meetings, get the  Academy of Otolaryngology ��" Head and Neck Surgery and your state society involved; this is not an acceptable policy.