Otolaryngology Coding Alert

Question: After an otolaryngologist performs an ethmoidectomy on a non-Medicare female, she returns for a follow-up visit. Following the exam, the patient remains in the office to receive her allergy shots. A nurse prepares the antigens and administers two injections to the patient. The payer denies the sinus-surgery office visit. How should I report the services?

Maine Subscriber


Answer: Depending on the denial reason, you should consider either appealing or resubmitting the E/M code 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). If the payer denies the office visit (99211-99215, Office or other outpatient evaluation and management for an established patient ...) as included in the ethmoidectomy global period (31254, Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]; or 31255, ... with ethmoidectomy, total [anterior and posterior]), you may appeal the denial with a letter explaining that the resource- based relative value scale (RBRVS) does not include postoperative care in the sinus surgery codes.

Although the National Physician Fee Schedule Relative Value File indicates zero global days for sinus endoscopy (31231-31294), some third-party payers impose their own 45- or 90-day global periods on the procedures. Because the office visit in your case is related to the ethmoidectomy (31254-31255), the payer may include the follow-up visit (99211-99215) in the surgical package and deny the related E/M service.

But if the payer denies the E/M as incidental to the allergy shots, you should resubmit the claim. Make sure to append modifier -25 to the office visit code to indicate that the E/M is a significant, separately identifiable service from the allergy treatment. Because you are billing a commercial carrier, you should use the complete service codes. Assign 95125 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; two or more injections) for preparing the antigens and administering the two injections.

To bolster your case that the E/M service is a significant, separately identifiable service from the allergy treatment, you should link the sinus diagnosis to the office visit and the allergy diagnosis to the allergy codes. For instance, if the patient has chronic ethmoidal sinusitis (473.2) and allergic rhinitis (477.9), report 99211-99215-25 linked to 473.2, and 95125 linked to 477.9.