Otolaryngology Coding Alert

Question: Our otolaryngologist performed a myringotomy and we billed it with 69420- LT. Unfortunately, the patient returned six days later complaining that her ear was still in pain, and the ENT gave her a middle ear steroid injection in our office, which we reported with 69801-78. Medicaid denied the injection, with the reason that the patient was still in the global period from the myringotomy. What should I have done differently?

Alabama Subscriber

Answer: It sounds like you coded the initial procedure correctly by reporting 69420-LT (Myringotomy including aspiration and/or eustachian tube inflation, Left side). However, you appear to have used the wrong modifier for the subsequent visit following the continued ear pain.

Here’s why: When the patient received the middle ear injection, you reported 69801-78 (Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal, Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period).

However, modifier 78 requires a return to the operating room (OR). In your case, the physician didn’t take the patient back to the OR. Instead, your patient did not get the desired outcome from the myringotomy and the physician was performing a new service, which took place in your office. And the ear pain really is not classified as a complication of the surgery. It reflects that the first surgery, the myringotomy had not achieved the treatment goals.

Because the initial surgery did not meet the treatment goals, your best bet is to append modifier 58 (Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period) to the procedure code for the second service, reporting 69801-58.