Otolaryngology Coding Alert

Question: A patient came to our office with a new complaint five weeks after having had a tonsillectomy (which our physician performed). The physician examined the patient and documented an E/M service. He then performed a nasal endoscopy and recorded a diagnosis of acute sinusitis. How should I report this? Is the E/M separate from the scope? Do I need modifiers because the service occurs during the global period of the tonsillectomy?


Arizona Subscriber


Answer: You will need several modifiers to report this claim correctly.

First, report the diagnostic endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]). Because the scope occurs during the global period of another procedure (in this case, tonsillectomy, for instance 42821, Tonsillectomy and adenoidectomy; age 12 or over), you should append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 31231. This distinguishes the scope as separate from and unrelated to the tonsillectomy--and tells the payer not to include payment for the scope as part of the tonsillectomy's global surgical package.

You say that the physician provided and documented a separate and significant E/M service, which presumably led to the decision to perform the scope. In this case, you should report the E/M service code best supported by your physician's documentation (e.g., 99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

Because the E/M occurred during the tonsillectomy's global period but was unrelated to the tonsillectomy, you should append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to 99213. This prevents the payer from folding the E/M service into the global package of the tonsillectomy.

To identify the E/M service as -above and beyond- the nasal endoscopy's minimal E/M component, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213. This will prevent the payer from bundling the E/M service into 31231.

Therefore, your final coding will be 31231-79, 99213 (or whichever service level the documentation best supports)-24-25.

Don't forget: Link a diagnosis of 461.x (Acute sinusitis) to 31231. You can link this same diagnosis to the E/M service code or (even better), link the E/M service to the signs-and-symptoms diagnoses that brought the patient to your office in the first place.