Otolaryngology Coding Alert

Question: An otolaryngologist places a paper patch (69610) on a patient's right ear and removes a tube from the patient's left ear. Medicare denied the claim. Was I correct to code it with modifier 59?

New Jersey Subscriber

Answer: You should code the scenario with only 69610 (Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch), not 69610-RT (Right side), 69424-59-LT (Ventilating tube removal requiring general anesthesia; distinct procedural service; left side).

Medicare always considers 69424 a component of 69610 and never allows a modifier to override the bundle. The Correct Coding Initiative (version 14.1) has a level 0 edit on 69610 and 69424.

Including a tube removal in a same-side tympanic membrane repair makes sense. But not allowing a modifier for a tube removal when it is the only procedure performed on that ear does not seem appropriate.

The code pair previously had a modifier indicator of "1," meaning you could have reported the scenario as you indicated and appealed for the separate-side payment. Now if the ENT places a patch on one ear and removes a tube from the other ear, he will not receive any payment for the removal. Abusing modifier 59 by using it to unbundle same-side patches and tube removals could have led to this automatic separate-side inclusion.