Question: A patient who is coming back for follow-up after unilateral endoscopic maxillary antrostomy with tissue removal and turbinectomy complains of a cough and fever. The otolaryngologist assesses and manages the problem and also carries out endoscopic sinus debridement on the patient. What modifiers do you need to report the encounter?
Answer: As the unrelated office visit as well as a staged debridement (planned staging for the endoscopic maxillary antrostomy) took place during the turbinectomy's 90-day global period, you will be required to use modifiers 24 (Unrelated evaluation and management service by the same physician during a postoperative period) with the EM service and modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) with the debridement. To show the E/M is a important and separate service from the debridement, you will also use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
Generally, you would not charge an E/M service that takes place within an active postoperative period. But as the otolaryngologist carries out the E/M service for a problem that is unrelated to the turbinectomy you must bill the office visit appended with modifier 24 for accurate medical coding and billing.
You must also use modifier 58 with the debridement code (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). Modifier 58 specifies that the otolaryngologist carries out a procedure -- debridement -- that is a planned staged procedure related to the therapy and healing to attain the desired results from the maxillary antrostomy.
The scenario's same-day service and procedure necessitate modifier 25 as 31237 is a minor procedure, which has a built in mini EM service. You would usually include a minor related E/M service with the debridement. But as the otolaryngologist in your example carries out an important and separate service from the debridement, you must also report the office visit (9921X, Office or other outpatient visit for the evaluation and management of an established patient …) appended with modifier 25.
Medical Coding and Billing Tip: Although the patient requires debridement because of sinus surgery, the antrostomy does not make global surgery modifiers necessary. Functional endoscopic sinus surgery (FESS) codes involving 31267 contain zero global days. Once a non zero global day surgery (such as 90 days) is carried out with the zero global day FESS surgery, that entire surgical encounter gets the longer global attached to it for the total time the longer global exists (such as the full 90 days).
Your ICD-9 coding must demonstrate the office visit's separate nature from the debridement as well as the turbinectomy. Different diagnoses will tell the insurer that the otolaryngologist assessed and managed a significant and separate problem from the day's procedure (31237) and that the problem is not related to the active postoperative period created by the turbinectomy. The debridement also must only have the maxillary sinusitis (473.0) associated with it, as it is staged to the 31267 and not linked to the the turbinectomy.
Here's how: You must link the definitive acute diagnosis, for instance upper respiratory infection (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site), to the E/M code. For the debridement, use the suitable sinus surgery diagnoses, for instance chronic maxillary sinusitis (473.0).
The claim could read:
CPT codes ICD-9 codes
9921X-24-25 465.9
31237-58 473.0
ICD-10: When your diagnosis coding system changes in 2013, you will use J32.0 (Chronic maxillary sinusitis) instead of 473.0. Instead of ICD-9 coding option 465.9, you'll report J06.9 (Acute upper respiratory infection, unspecified).
Answer: As the unrelated office visit as well as a staged debridement (planned staging for the endoscopic maxillary antrostomy) took place during the turbinectomy's 90-day global period, you will be required to use modifiers 24 (Unrelated evaluation and management service by the same physician during a postoperative period) with the EM service and modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) with the debridement. To show the E/M is a important and separate service from the debridement, you will also use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
Generally, you would not charge an E/M service that takes place within an active postoperative period. But as the otolaryngologist carries out the E/M service for a problem that is unrelated to the turbinectomy you must bill the office visit appended with modifier 24 for accurate medical coding and billing.
You must also use modifier 58 with the debridement code (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]). Modifier 58 specifies that the otolaryngologist carries out a procedure -- debridement -- that is a planned staged procedure related to the therapy and healing to attain the desired results from the maxillary antrostomy.
The scenario's same-day service and procedure necessitate modifier 25 as 31237 is a minor procedure, which has a built in mini EM service. You would usually include a minor related E/M service with the debridement. But as the otolaryngologist in your example carries out an important and separate service from the debridement, you must also report the office visit (9921X, Office or other outpatient visit for the evaluation and management of an established patient …) appended with modifier 25.
Medical Coding and Billing Tip: Although the patient requires debridement because of sinus surgery, the antrostomy does not make global surgery modifiers necessary. Functional endoscopic sinus surgery (FESS) codes involving 31267 contain zero global days. Once a non zero global day surgery (such as 90 days) is carried out with the zero global day FESS surgery, that entire surgical encounter gets the longer global attached to it for the total time the longer global exists (such as the full 90 days).
Your ICD-9 coding must demonstrate the office visit's separate nature from the debridement as well as the turbinectomy. Different diagnoses will tell the insurer that the otolaryngologist assessed and managed a significant and separate problem from the day's procedure (31237) and that the problem is not related to the active postoperative period created by the turbinectomy. The debridement also must only have the maxillary sinusitis (473.0) associated with it, as it is staged to the 31267 and not linked to the the turbinectomy.
Here's how: You must link the definitive acute diagnosis, for instance upper respiratory infection (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site), to the E/M code. For the debridement, use the suitable sinus surgery diagnoses, for instance chronic maxillary sinusitis (473.0).
The claim could read:
CPT codes ICD-9 codes
9921X-24-25 465.9
31237-58 473.0
ICD-10: When your diagnosis coding system changes in 2013, you will use J32.0 (Chronic maxillary sinusitis) instead of 473.0. Instead of ICD-9 coding option 465.9, you'll report J06.9 (Acute upper respiratory infection, unspecified).
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