Otolaryngology Coding Alert

Question: After having a septoplasty (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) last week, the patient visited the office with a surgeryrelated hematoma. The doctor did not charge for the drainage. Two days later the hematoma returned andthe doctor's partner drained it in the office. The second ENT performed a repeat procedure and isn't receiving payment for the surgery. Should the first doctor have charged for the I&D? Can the second doctor report the service with modifier 77?

New York Subscriber

Answer: The answer is two-fold: CPT indicates that treatment for complications is not included in the global and is separately reportable. Medicare, however, considers complications part of the global and not  separately reportable unless they involve a return to the operating room.

So, if your patient is not a Medicare patient and the patient's payer has not stated that it follows Medicare post-op guidelines, report the first post-op visit as a separate, significantly identifiable E/M and hematoma drainage per CPT guidelines.

The following advice applies to the first post-op visit when the patient presents with the hematoma and the physician drains it:

• Use the appropriate level E/M (99212-99215,Office or other outpatient visit for the evaluation and management of an established patient ...) to indicate the visit is not related to the global period (from the septoplasty's 90 day global).

• Append modifier 24 (Unrelated E/M by the same physician during post-op period).

• Use the post-op hematoma diagnosis (729.92, Nontraumatic hematoma of soft tissue), not the reason for the surgery diagnosis (470, Deviated nasal septum).

To report for the surgery (10140, Incision and drainage of hematoma, seroma or fluid collection), you also need modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the E/M. The modifier shows that you did a separate and significant E/M service (assuming you did).

Then for the incision and drainage (I&D) of the hematoma, you need to use modifier 79 (Unrelated procedure during the post-op period). Again, report the "unrelated" diagnosis, the post-op hematoma.

For the second visit, the doctor probably did not do a separately significant E/M, so you report only the I&D with modifier 79.

For repeat procedures, although the payer should recognize modifier 76 (Repeat procedure or service by same physician), many payers accept 76 and 77 (Repeat procedure by another physician) modifiers only for diagnostics and do not pay when these modifiers are tied to therapeutic procedures. Check with individual carriers for guidance.