Otolaryngology Coding Alert

Override edit with modifier 59, when appropriate Your multiple-procedure modifier claims will contain the correct appendage, if you use modifier 51, unless the insurer bundles the code set inappropriately.

Otolaryngology coders often have a hard time distinguishing multiple-procedure rules from distinct procedural services. "I am not sure when I should use 51 and when I should use 59," says Delores Munson, insurance clerk for Pradip K. Mistry, MD, in Norfolk, Neb.

Test your modifier skills with a real-world scenario. Which Modifier Applies to Throat/Ear Procedures? An otolaryngologist performs a tonsillectomy and adenoidectomy (42820-42821, Tonsillectomy and adenoidectomy ...) and a bilateral myringotomy with tubes (69433-69436 with modifier 50, Tympanostomy [requiring insertion of ventilating tube] ...; bilateral procedure). "Should I use modifier 51 (Multiple procedures) on the BMT because the two procedures are not bundled?" Munson asks.

Did you agree that Munson should use 51? If so, you're right. "If the payer doesn't inappropriately bundle the procedures with 51, you wouldn't use modifier 59 (Distinct procedural service)," says Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Shrewsbury, N.J. Here's why: If 51 Applies, Use It When an otolaryngologist performs two procedures that the insurer doesn't bundle, modifier 51 applies. For instance, the National Correct Coding Initiative does not contain a T&A/BMT (42820-42821/69433-69436) edit. Therefore, modifier 51 appropriately describes the procedures as multiple procedures.

Always look to modifier 51 first. "Modifier 59 is the modifier of last resort," Cobuzzi says. You should report the modifier only when no other modifier more appropriately describes the code pair, and if modifier 59's definition applies.

Not All Insurers Require 51 Even though reporting a T&A/BMT with modifier 51 follows CPT principles, not all insurers require it. Some Medicare carriers, including Empire and Missouri, instruct you not to put 51 on a multiple-procedure claim, Cobuzzi says. "The carrier will do it for you," she says.

With a T&A claim, you will likely bill a private payer. If the insurer requires modifier 51, you would append the modifier to the lesser-valued procedure - the BMT. The claim could read:
  42820 - ... under age 12 years
with 474.10 - Hypertrophy of tonsils with adenoids
(7.50 RVUs or $284.23 national rate; bill 100
percent; receive 100 percent)
  69436-51 - Tympanostomy, general anesthesia
with 381.19 - Other chronic serous otitis media
(4.44 RVUs or $168.26 national rate; bill 150 percent; receive 75 percent). Private Edit Can Make 59 Valid Unfortunately, NCCI doesn't offer the final word on a code pair. Although a T&A (42820-42821) and BMT (69433-69436) are not usually bundled, a private payer may have an edit that causes a claim denial.

Solution: Resort to modifier 59 on the lesser procedure. In this case, modifier 59 is appropriate because the T&A and [...]