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?


Illinois Subscriber

Answer: Because the unrelated office visit and debridement occur during the turbinectomy's 90-day global period, you will need to use modifiers 24 and 79. To indicate the E/M is a significant and separate service from the debridement, you will also use modifier 25.

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 (31267, Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus), you should also bill the office visit appended with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

You should also use modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) on the debridement code (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). Modifier 79 indicates that the otolaryngologist performs a procedure--debridement--that is unrelated to the active postoperative period--the turbinectomy-s.

The scenario's same-day service and procedure necessitate modifier 25. 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 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

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.

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 (31267).

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
- 31237-79                      473.0
- 9921x-24-25                 465.9.

Answers to You Be the Coder and Reader Questions provided and/or reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Fall, 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.