Wiki CPT 31237 W/Modifier 79

gvarnes7

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Patient had FESS. During post op doctor billed 31237-50-79, insurance is denying modifier 79 as invalid/not appropriate modifier with procedure code. I have read articles that say modifier 79 is appropriate with 31237 during post op but I have also read that it is not appropriate. When billing post op debridement's do you use modifier 79???

Thank you in advance for your help.
 
Modifier 79 is appropriate with this code, but needs to be supported by documentation that the procedure your physician is billing was unrelated to the surgery that has the global period. I know that some payers believe that this modifier is often abused to obtain payment for services that are part of routine post-operative care which is part of the global payment, so it would not surprise me to see this denial.

If this debridement was post-operative care that did not require a return trip to the OR, then most likely the modifier is not supported and the denial is correct. However, if your documentation indicates that this debridement was completely unrelated to the original surgery (e.g. it was done for an unrelated problem or a separate condition), then you may wish to appeal the denial with notes that support this.
 
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Normally FESS doesn't have Global period,this is because the procedure doesn't charge for the post-op care. : Functional Endoscopic Sinus Surgery Codes (CPT codes 31231-31288 - except 31239) do not have a global period. (0 days per CMS). Post-op debridements are commonly performed after FESS and typically billed with CPT 31237. No modifier is required since FESS procedures do not have a global period. So you would not need mod. 79.

If the Dr. performed a procedure at the same time that does have a global then the mod 79 needs to be in the first spot then mod 50 . Hope that helps.
 
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