Claim Denial with Modifiers 24/58

Question:

I have been getting denied for office visits (99212-99215) billed during a global period. I bill the E/M code with a modifier 24, and/or 58 and the claims still get denied for “separately billed services/tests as they are considered components of the procedure. Separate payment is not allowed.” According to the conferences I have attended for KZA, we’ve been told that we can bill and E/M code with modifier 24, but the insurances do not cover it. Do you have any other suggestions on how to get these claims paid?

Answer:

Thank you for your question. Billing an E/M service during a global period can be tricky, especially when insurers bundle them into the procedure. Here are some strategies to improve claim approvals:

1. Ensure Documentation Supports the Modifier

• Modifier 24: Must show that the E/M service is unrelated to the procedure. If the visit is for post-op care, insurers will likely deny it.

• Modifier 58: Used for staged or related procedures, not routine post-op visits or visits unrelated to the procedure.

2. Check Payor-Specific Guidelines

• Medicare and private payors may interpret what qualifies as an unrelated E/M service differently.

• Some payors require additional documentation proving medical necessity.

3. Use Diagnosis Codes That Support Unrelated Services

• If the diagnosis code is too closely related to the procedure, payors may still bundle the visit.

• Consider adding supporting notes explaining why the visit was medically necessary.

4. Appeal Denied Claims

• If you believe the denial was incorrect, submit an appeal with detailed documentation.

• Include payor guidelines that support separate reimbursement.

*This response is based on the best information available as of 7/17/25.

Evaluation and Management Service on the Same Date as an Office Procedure

Question:

A patient came into the office for a balloon sinus ostia catheterization and dilation of the maxillary, sphenoid and frontal sinuses bilaterally. My surgery scheduler has already obtained pre-certification for the procedure as it is covered in the office setting. I performed an examination and then did the procedure. I then performed a sphenoid, frontal, and maxillary dilation bilaterally. Can I bill an E/M service since I examined the patient?

Answer:

No, since the focus of the visit was the procedure and you have already obtained precertification for the procedures on the sphenoid and frontal sinus dilation (CPT 31298-50) and the maxillary dilation (31295-50), the E/M service is inherent to the procedure and should not be reported separately.  In this situation there is not a significant separate identifiable justification for an E/M service.

*This response is based on the best information available as of 7/03/25.

Ablation of Thyroid Nodules

Question:

My physician performed a percutaneous radiofrequency ablation of 3 thyroid nodules, one in the lower part of the left lobe and 2 in the right lobe. I am not sure what CPT code I should report. Can you help?

Answer:

Certainly. There are 2 new CPT codes to report percutaneous radiofrequency ablation of thyroid nodules: CPT code 60660 (Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, including imaging guidance, radiofrequency) and CPT code 60661, an add-on code for the additional lobe. In this instance, you will report 60660 for the left lobe and 60661 for the right lobe. Keep in mind that imaging guidance is included and should not be reported separately.

*This response is based on the best information available as of 6/19/25.

Myringoplasty using a Water-insoluble, Off-white, Nonelastic, Porous, and Pliable Product

Question:

If a physician performs a myringoplasty and uses a water-insoluble, off-white, nonelastic, porous, and pliable product, would it be appropriate to report code 69620 alone or 69620 appended with modifier 52, Reduced Services?

Answer:

No, if the preparation of the perforation edges and a water-insoluble, off-white, nonelastic, porous, pliable product was used as a patch to the drum defect, code 69610, Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch, would be reported. If a tissue graft was harvested and edges prepared for the drum defect repair, then code 69620, Myringoplasty (surgery confined to drumhead and donor area), would be reported.

*This response is based on the best information available as of 6/05/25.

Septoplasty with a Nasal Swell Body Reduction

Question:

I performed a Septoplasty for a patient with a deviated nasal septum. During the procedure, I also performed a nasal swell body reduction on the septal mucosa. My coder told me I could report 30520 for the Septoplasty but I could not report the lesion excision with 30117. I don’t understand why I cannot report both codes together. Can you advise?

Answer:

Your coder is correct. According to CPT Assistant (6/19), it is not appropriate to report code 30117, excision or destruction (e.g., laser), intranasal lesion, internal approach, separately. The procedure described in code 30117 is included in code 30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft, and should not be reported separately.

*This response is based on the best information available as of 5/22/25.

Epistaxis

Question:

If I perform a nasal endoscopy to localize the site of a nosebleed, then remove the scope and use a nasal speculum to cauterize, can I report both 31231 and 30901?

Answer:

You should not report both CPT code 31231 and 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method) for this procedure.  CPT code 30901 would be the most appropriate choice for cauterizing a nosebleed. 31231 is a diagnostic procedure and includes the parenthetical statement “separate procedure.” This code is included in a more definitive therapeutic/treatment procedure at the same operative session. Report either CPT code 31231 or 30901, but not both codes.

*This response is based on the best information available as of 5/8/25.