Description
This policy addresses postoperative endoscopy and debridement following a sinus surgery.
Policy Application
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Policy
Postoperative sinus endoscopies (31231) and debridements (31237, S2342) are considered related to all nasal and sinus procedure codes performed at the original surgical session if rendered for the same condition on the same date of service or within the global period. Additional information on Global Surgery can be found in the Global Surgical Package policy.
When postoperative sinus endoscopies (31231) and debridements (31237, S2342) are reported within the global period of a sinus surgery with the same/similar diagnosis code(s), the claim line will be rejected if modifier 79 is appended. BCBSND will not allow the use of modifier 79 if the same or similar diagnosis codes are submitted.
Providers must report an appropriate modifier for postoperative sinus endoscopies (31231) and debridements (31237, S2342). Documentation must support the services being performed.
- Modifier 79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
- Append only when the services are unrelated during the global period; a sinus endoscopy or debridement would be considered related to the surgical session within the global period if provided for the same/similar diagnosis code(s).
- Modifier 78 – Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
- Append when post operative complications require a return to the operating room for a related procedure.
- Modifier 58 – Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
- Append when the care is performed in the office as these would be considered a staged or related procedure.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
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