Otolaryngology Coding Alert

Modifier 59 might apply even when you use the same code You could mislabel a modifier 59 procedure as a modifier 76 one and incorrectly get full payment, if you fail to check that the second procedure occurs on the same anatomy. Modifier 76 per CPT is a repeat procedure or service by the same physician, says Therese Burke, BS, CPC, a coding instructor and consultant with Medical Office Alternatives in Chepachet, R.I. You use it to let the payers know that the claim is not a duplicate. If the otolaryngologist didn't do the same procedure twice, you should use modifier 59 (Distinct procedural service) instead of modifier 76 (Repeat procedure by same physician). Modifier 59 identifies "procedures or services that are not normally performed together, but under the circumstances are appropriate." Test yourself with these two scenarios. 1. Is Epistaxis at Same Place, Encounter? An otolaryngologist performs epistaxis twice in the same session. He uses a nitrate stick to cauterize a frontal bleed before taking a film and then post-film cauterizes the same anterior area. Should you use modifier 59 or 76 for the second epistaxis control? You would use modifier 76 on 30901 (Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method), says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. Because the physician did the same procedure twice on the same location, modifier 59 is not appropriate, she says. "The key word here is SAME," Burke stresses. Modifier 76 is not subject to a payment reduction. Tip: Report the epistaxis control on two lines. For instance, if the physician performed and documented a significant, separately identifiable E/M service prior to performing the cauterizations, and reviewing and interpreting the in-office nasal bone x-ray (70160, Radiologic examination, nasal bones, complete, minimum of three views), the claim could contain: Dx 1: 784.7 (Epistaxis) Exception: If the bleed control had occurred at separate sessions, you would then call on modifier 59. For instance, a physician performs simple epistaxis anterior control in the office in the am and then has to cauterize the same site in the emergency room (ER) in the p.m. Because the controls occur at separate sessions, you would use modifier 59 on the second hospital epistaxis control code. "The key word here is DIFFERENT," Burke points out. Qualifying circumstances include a different session, different procedure, different site, separate incision or lesion. Reminder: When filing the above encounters, make sure you switch place-of-service (POS) codes and use different forms to accommodate each address. For the initial 30901, you would use POS 11 (Office). Then for the ED 30901-59, use a new claim [...]