Thanks for your query,
When any one of the original surgical procedures carry a global period:
Modifier 79 is not valid when attached to CPT codes 31231, 31237, S2342 for any sinus endoscopy and/or debridement performed within that global period. The use of modifier 79 in this circumstance to characterize 31231, 31237, or S2342 as “unrelated” to the procedure code with the global period is inaccurate, and an inappropriate use of modifier 79. The sinus endoscopy or debridement is related to the surgical session with the global period, regardless of which procedure code the surgeon deems the endoscopy/debridement to be related. (Moda HealthA) Postoperative sinus endoscopies and/or debridements are potentially eligible for separate reimbursement when coded and documented correctly, but not when modifier 79 is used.
Moda Health will deny 31231-79, 31237-79, or S2342-79 as an invalid procedure code-modifier combination. Provider appeals will only be approved if the written documentation submitted for review shows that the original surgery creating the global period was performed on a body part other than the nasal or sinus structures.
Postoperative sinus endoscopies (31231) and/or debridements (31237, S2342) submitted as a staged procedure (modifier 58 attached) will be separately reimbursed when the staged relationship is supported in the medical record by documenting the anticipated need for probable endoscopy and/or debridement procedures.
i. Regarding modifier 58 (related, staged), the CPT Assistant states, “Decisions to perform subsequent procedure(s) may depend on the outcome of the surgery and the patient's postoperative status. The term anticipated was added because physicians can anticipate the potential for subsequent procedure(s) but cannot always predict it.
ii. Moda Health recognizes the exact timing and number of needed sinus endoscopy and/or debridement procedures is not known at the time of the original surgery. However, the anticipated need for endoscopies and/or debridements and the estimated time frame for assessing this need must be included in the medical record documentation. This information may be included in the operative report for the original surgery or the preoperative documentation. Regardless of where the surgeon chooses to include this information, the office should be prepared to submit this supporting documentation upon request for review to support the billing of 31231,
31237, or S2342 as a staged procedure.
iii. The CPT Assistant also states, “The Centers for Medicare and Medicaid Services (CMS) and most other payers do not accept modifier 58 with any procedures having a global surgical period of zero days.”1 Moda Health has been unable to locate CMS documentation to this effect. Moda Health will accept modifier 58 with 31231, 31237, or S2342 when the medical record documents the anticipated need of the postoperative endoscopy and/or debridement to support staged relationship to the original surgery.
iv. Note: Frequent, multiple, or repeated staged postoperative sinus endoscopies and/or debridements may also be subject to review for medical necessity.