Otolaryngology Coding Alert

Question: An otolaryngologist billed 99282, 30520 and 30903 on day one. Three days later, the ENT admitted the patient to the hospital for recurrent epistaxis and packed his nose again. The physician saw the patient daily for follow-up and discharged him five days later. Should I code the admit, packing and follow-up visits as the ENT has indicated? Georgia Subscriber Answer: To determine if you can code the services and procedure that occur later in the week, check the patient's insurer's global surgical package. Medicare pays only for complications that require a return trip to the operating room. Therefore, if the patient's coverage is Medicare or a payer that follows Medicare surgical guidelines, you cannot charge for the non-OR hospital care and packing. The carrier bundles these services and procedure in the septoplasty's 90 global days (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft). CPT surgery guidelines, however, do not include complications. "Complications - requiring additional services should be separately reported," states the AMA on page 47 of the CPT 2008 manual. For insurers that follow CPT surgery guidelines, you should report the E/M services and packing linked to 998.11 (Other complications of procedures, not elsewhere classified; hemorrhage complicating a procedure) and 784.7 (Epistaxis). To indicate that the packing (30901-30905) is separate from the septoplasty, you should append 3090x with modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). Although the bleed is related to the postoperative period, no modifier exists for "related but not in the OR," making modifier 79 your only option. You-ll need two modifiers on the initial hospital care code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient -). Use modifier 24 (Unrelated E/M service by the same physician during a postoperative period) to identify the E/M service as separate from the septoplasty's postoperative period. Also, attach modifier 24 to 99231-99233 (Subsequent hospital care, per day, for the E/M of a patient -). For initial hospital care that is significant and separate from the packing, also append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99221-99223.