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 [...]