Otolaryngology Coding Alert

Question: My otolaryngologist performs a tonsillectomy and typanostomy on the same day in the operating room. Should I report both operations and append modifier -59 (Distinct procedural service) to one procedure? If so, which code should I use with modifier -59 and why? Will the insurer reduce payment for the second operation?

Nebraska Subscriber

Answer: You should report both the tonsillectomy (such as 42825, Tonsillectomy, primary or secondary; under age 12) and the tympanostomy (69436, Tympanostomy [requiring insertion of ventilating tube], general anesthesia). Bill the tonsillectomy first because it has more relative value units (7.35) than the tympanostomy (4.14 RVUs). To indicate a bilateral tympanostomy, append modifier -50 (Bilateral procedure) to 69436.

Because carriers do not bundle 69436 into 42825, you should not append the "unbundling" modifier -59 to the lesser-valued procedure (tympanostomy). In addition, you will report two separate diagnoses for the operations, which should help the insurer realize that these are separate procedures.

Since you are billing for multiple procedures, you should also append modifier -51 to 69436. Even if you omit the modifier, payers will automatically insert modifier -51 when processing the claim. The insurer will reduce payment for the second procedure (Medicare and most payers cut payment in half).