Otolaryngology Coding Alert

Overuse of modifier -59 (Distinct procedural service) raises red flags and invites audits. But, knowing some typical otolaryngology scenarios in which to use it will steer you to the path of reimbursement success. Epistaxis Occurs at Different Session When an otolaryngologist controls nasal bleeding at a separate, operative session - a procedure that is usually bundled - it may warrant individual billing with modifier -59 on the lower-valued code.

For instance, suppose a patient who has a nosebleed presents to his otolaryngologist at 8 a.m. The physician uses a scope to control the bleeding. At 2:30 p.m., he returns due to another nasal hemorrhage, which the otolaryngologist controls with packing. Report 31238, 30903-59. For the first encounter, the otolaryngologist bills the scope control-of-bleeding code 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage). For the afternoon visit, the doctor assigns packing of epistaxis code 30903* (Control nasal hemorrhage, anterior, complex [extensive cautery and/or packing] any method).

The Correct Coding Initiative (CCI) bundles 30903 with 31238. However, the situation meets the definition of modifier -59. These procedures are 1) separate and distinct, 2) not usually performed together, and 3) performed at different operative sessions. You should report both the scope (31238) and the packing (30903) appended with modifier -59 to indicate a different operative session. "

Append modifier -59 to the lower relative value unit (RVU) procedure, no matter what was done second," says  Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryn-gology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. The scope (31238) is a higher-valued procedure (7.24 RVUs) than the packing (30903, 4.86 RVUs). So, append modifier -59 to 30903. If the procedures are reversed and the otolaryngologist packs the epistaxis first and uses the scope in the afternoon, the coding remains the same.

"Documentation is king," Cobuzzi says. It's easy to show that different operative sessions occurred when the place of service is different. But, when the procedures take place at the same location, documentation must clearly reflect that a separate, operative session occurred. A note stating "The patient has returned with a nosebleed" makes it clear that two sessions exist, Cobuzzi explains.  Sinus Surgery Is Performed on Different Sides  When an otolaryngologist performs sinus surgery on different sides on the same day, the procedures are separately reportable. Consider an otolaryngologist who performs a partial ethmoidectomy on a patient's left side and a total ethmoidectomy on the right side. Assign 31255, 31254-59. For the partial ethmoidectomy, the surgeon reports 31254-LT (Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial [anterior]; Left side). For the total ethmoidectomy, she uses 31255-RT (& with ethmoid-ectomy, total [anterior and posterior]; Right side). CCI bundles 31254 into 31255. Normally, you would report either part [...]