Otolaryngology Coding Alert

We'll tell you which modifier will make insurers pay up Although you may blame payers for frequent denials of postoperative procedures, such as a second radical neck dissection (RND) performed during 38724's global period, sometimes the modifier is the real culprit.

"Some payers have software edits that automatically reject procedures performed when a global period exists," says Tara R. Ritter, appeals coordinator for American Physician Services, which serves multiple ENT, allergy, sinus and head and neck practices in Atlanta. For instance, Blue Cross Blue Shield's system threw out all claims filed during a postoperative period, regardless of modifier, Ritter says. After she contacted the insurer's medical director, the payer corrected its system to recognize modifiers. "If an insurer consistently rejects postoperative claims, check with your provider representative to get the system fixed," she says.

Make sure you use the right modifier to explain how the postoperative procedure relates to the postoperative period, says Jay B. Horowitz, MD, clinical assistant professor of surgery/otolaryngology at Robert Wood Johnson Medical School in New Jersey. "Otherwise, the carrier won't pay the first time that you file," he says. To determine the correct postoperative procedure modifier, ask "How is the subsequent procedure related to the postoperative period?" Ritter says. When a global period is in effect, you should choose from these modifiers:

-58 - Staged or related procedure or service by the same physician during the postoperative period

-78 - Return to the operating room for a related procedure during the postoperative period

-79 - Unrelated procedure or service by the same physician during the postoperative period. But applying the appropriate modifier can prove elusive even to the most experienced otolaryngology coder. So, try your hand at four common otolaryngology examples to avoid appealing additional post-op procedures for incorrect appendages. Bilateral RND Follows Unilateral Dissection Suppose a patient needs a bilateral neck dissection. Due to the risk involved in the operation, the otolaryn-gologist first performs the RND (38724, Cervical lymphadenectomy [modified radical neck dissection]) on the right side, which has 90 global days. A week later, he performs the contralateral side (38724-LT [Left side]). So, how is the second procedure related to the primary procedure's global period? In this scenario, the otolaryn-gologist planned to perform one portion of a procedure at one session and to complete the procedure at a later date, Horowitz says. Because the second resection (38724-LT) was planned at the time of the first resection (38724-RT), the second surgery is a staged procedure, he says. Therefore, you should report the second resection (38724-LT) and append modifier -58 (38724-58-LT). Malignancy Needs Additional Excision When a surgeon removes a malignancy and the pathology report shows that the excision did not fully remove [...]