Question: One of our commercial payers has been denying the bilateral portion of 31237 for the past several months. I have appealed using modifier 79 on the first line and modifier 50 on the second, but only two of the claims have been reconsidered. The payer states that it has “global policy days” that justifies not paying for bilateral. I’m reporting the diagnosis code that corresponds to the FESS procedure done, so feel like the payer is making up its own rules. What do you suggest?
New Mexico Subscriber
Answer: You should appeal the decision. Include a note stating that 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) can be billed bilaterally, which supports including modifier 50 (Bilateral procedure) when applicable. Include a copy of guidelines supporting the use of 31237 as bilateral, such as the CPT® page for code 31237 that includes the note, “This code represents a unilateral service, meaning performed on one side. Append modifier 50 if the provider performs the procedure bilaterally or use modifiers RT/LT, depending on payer preference.” In addition, the payer might also want you to include modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professionals during the postoperative period) on both lines of the claim. If so, you will have two separate lines as 31237-50-79.
Do not include the diagnosis for whatever CPT® code/surgical procedure that had global a global period (such as 470, Deviated nasal septum).