Otolaryngology Coding Alert

Question: When should I use modifier -59 instead of modifier -51?

Michigan Subscriber Answer: You should append modifier -59 (Distinct procedural service) to a secondary surgical procedure when the National Correct Coding Initiative (NCCI) bundles the codes, if the scenario justifies unbundling the code set. But when your otolaryngologist performs multiple operations that NCCI doesn't bundle, use modifier -51 (Multiple procedures).

Compare these two typical ENT examples:

1. An otolaryngologist performs a tonsillectomy and deep lymph node excision on a 10-year-old boy. Because NCCI doesn't bundle these codes, you don't need modifier -59 to obtain payment for the second procedure.

You should instead report the tonsillectomy and excision as multiple procedures. Report the higher-valued procedure first: the tonsillectomy with 42825 (Tonsillectomy, primary or secondary; under age 12) (7.71 relative value units). Then, submit the biopsy (42804, Biopsy; nasopharynx, visible lesion, simple) (3.14 RVUs). To indicate that the otolaryngologist performed multiple procedures, append modifier -51 to 42804.

In contrast, you should use modifier -59 to report two procedures that NCCI would normally bundle. Remember, this is the modifier of last resort. Before appending the modifier, check that the procedures' circumstances, such as a different operative session or anatomic location, allow you to separately report the codes.

2. An otolaryngologist performs a complete glossectomy with a radical neck dissection (RND) on a patient's right side and a complete cervical lymphadenectomy on the patient's left side. Normally, NCCI bundles a neck dissection into the glossectomy code. But because the RND occurs on the opposite side, you should separately report the procedure.

Here's how: Report the higher-valued procedure - the glossectomy, which includes a neck dissection on the right side - with 41145-RT (Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection; right side) (51.73 RVUs). Then, code the lymphadenectomy (second neck dissection) on the left side as 38720-59-LT (Cervical lymphadenectomy [complete]; left side) (25.90 RVUs). Modifier -59 informs the payer that because the otolaryngologist performed the procedures on separate sites, he deserves payment for both.