Otolaryngology Coding Alert

Question: A patient had a septoplasty and a submucosal inferior turbinate reduction. One month later, the physician performed a diagnostic nasal endoscopy following complaints of pain in the nasal cavity. Why would we have received a denial for an invalid denial when submitting 31231 with modifier 79?

Illinois Subscriber

Answer: There’s no way to definitively infer as to why the payer denied the claim without speaking to a representative for further elaboration. However, given the circumstances surrounding the submission, you may be able to apply some deductive reason to determine the cause of the denial.

First, you’ll want to have a look at the global periods for codes 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) and 30802 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal)).

Code 30520 has a global period of 90 days, while 30802 has a global period of 10 days. Therefore, the denial has to do with the submission of 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)) within the global period of 30520. You’d think that the application of modifier 79 (Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period) would override the potential for a denial, but that’s not always the case. While the reason for the denial is stated as related to the modifier, you’ve also got to consider the diagnosis at hand.

The denial might have something to do with the submission of 31231 during the global period of 30520 with the appropriate ICD-10-CM code for nasal pain, J34.89 (Other specified disorders of nose and nasal sinuses). While the denial code relates to the modifier, the payer has no way of telling whether the diagnosis code is actually unrelated to the septoplasty the physician performed a month prior — which puts modifier 79 in question as well.

Your best course of action is to file for an appeal that includes justification for the surgery and a detailed explanation as to why the diagnostic endoscopy is unrelated to the septoplasty from a month prior.