Otolaryngology Coding Alert

Question: A private insurer denied a claim for 30117 with modifier 50 (Bilateral procedure) because the payer's system does not consider the code reimbursable as bilateral. The representative advised me to change the claim to two units of 30117 and no modifier. Should I appeal the denial or follow her advice?

Georgia Subscriber

Answer: You should resubmit the claim using two units to indicate multiple lesion excisions or destructions (30117, Excision or destruction [e.g., laser], intranasal lesion; internal approach). A code that is eligible for bilateral procedure (modifier 50) reporting describes a procedure that the surgeon may perform on the right and/or left side(s).

Problem: Code 30117 represents intranasal lesion excision or destruction. The lesion can be anywhere on the inner nose, not just on the right or left side. The code also specifies "lesion" singular, not plural. So if the otolaryngologist removes lesions from different sites, you should use units or modifier 59 (Distinct procedural service).

Treat 30117, as well as 30118 (- external approach [lateral rhinotomy]), like codes 11400-11446 (Excision -- benign lesions) or 11600-11646 (Excision -- malignant lesions), which are also not unilateral or bilateral. If an otolaryngologist removes a lesion from the left cheek and the right cheek, you do not use modifier 50. You report units or modifier 59, depending on the lesion removals:

- For two excisions in the same anatomy and size classification, you would use units. Example: If an otolaryngologist removes a 0.6-cm lesion from a patient's left cheek and a 1.0-cm lesion from the patient's right cheek, you should report two units of 11441 (Excision, other benign lesion including margins, except skin tag [unless listed elsewhere], face, ear, eyelids, nose, lips, mucous membrane; excised diameter 0.6 cm to 1.0 cm).

- Switch to modifier 59 when the excisions do not fall under the same CPT code. Example: An otolaryngologist removes a 0.3-cm lesion from a patient's left ear and a 0.8-cm lesion from the right side of a patient's nose. To indicate that the payer should not consider 11440 (- excised diameter 0.5 cm or less) a component of 11441, you should use modifier 59 on 11440. The modifier shows that the 11440 occurred at a separate site from 11441.

Watch out: If an insurer doesn't recognize units, you might need to use modifier 59 in both of the above cases. Because modifier 59 is the modifier of last resort, reserve this method for payers that don't recognize or pay units. Some payers may require you to report 30117 multiple times with modifier 59 to indicate separate sites.

Time-saver: A quick look-up of 30117 in the Medicare Physician Fee Schedule could have saved you the hassle of having to resubmit the claim. Column "Z" of the fee schedule indicates bilateral surgery does not apply to 30117. The bilateral adjustment is inappropriate for this code because of anatomy -- the lesion(s) can be located anywhere intranasally. Therefore, you should report destruction of two intranasal lesions with 30117 x 2 (or 30117, 30117-59), not 30117-50.