# New to ENT.  Lots of Questions re: when to bill E/M with a scope



## mitchellk (Jan 31, 2016)

Hi.  I'm new to ENT coding and I have several questions that I hope you can help me with.  First when the doctor does a laryngoscopy in the office, how do you count this in the data complexity part of the audit sheet?  I'm thinking that he should get a point in the medicine part-- The same line where they get a point for reviewing/ordering an echo/ekg/cardiac cath.

Second -- When is it appropriate to use the code for the operating binocular microscope?  For example my doctor wants to know if he uses the microscope to place an ear wick can he charge for both the ear wick and the microscopic exam?

Third -- When charging a new patient office visit for a patient for hoarseness and the doctor does a laryngoscopy -- can he charge both the E/M code and the laryngoscopy?  Or only the laryngoscopy?  Do I assume since the patient came in for hoarseness that the doctor was already planning on doing the scope and in that case only the scope should be charged and not the E/M?  Also the same for nasal endoscopy.  How do I know when I can charge both the scope and the E/M vs just the scope?

My last question is regarding a patient who is on blood thinners.  He came to the ENT office because of frequent nosebleeds.  He was not actively bleeding at the time of the visit.  The doctor used an electric cautery to cauterize his nose to prevent further bleeding.  Can I charge both an E/M and the cauterization or just the cauterization?  Does the doctor need to state in his dictation that he made the decision to cauterize after examining the patient in order to bill both the E/M and the procedure?

I know this is a lot of questions, but being so new at coding I have a lot to learn!   I would love any advice anyone can give me!
Thanks!!!


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## tag60 (Mar 23, 2016)

I was searching this forum for an answer to coding E/M with minor procedure on same day (is it allowed?) and came across this post by mitchellk. Alas, it has not been answered! I seem to find different answers to this and hope someone will take another look at it.

An AAPC article on coding E/M on same day as a procedure says you would not code both when it is a minor procedure (0 or 10 days global) because the work done to assess, perform, and evaluate are inclusive in the procedure code. So from that article (link below) I understand that you would not bill for both, just for the laryngoscopy since there is no significant, separately identifiable E/M service performed in poster's question.

However, I then came across another article in "For The Record" (link below) which gives the same example as poster's question and states you may bill for both since the procedure was not anticipated. Some (not all) of my coding colleagues tell me the same thing, that if the procedure was not already scheduled or the condition not previously evaluated, you may pick up both the E/M and the procedure (with modifier -25).

I would like a consistent answer to this, please! Am I misunderstanding something?

AAPC article:
https://www.aapc.com/blog/30916-reporting-an-em-service/

For The Record (see "examples of appropriate use"):
http://www.fortherecordmag.com/news/022112_exclusive.shtml


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## ltrue (Apr 1, 2016)

*Thoughts to ponder....*

A couple things you want to remember when trying to decide whether or not to bill a separate E/M code:

1) Do you have a separate diagnosis from the diagnosis for the scope?  For example, does the patient have allergic rhinitis and an ear infection?  If so, you can bill the ear infection under the E/M and the allergic rhinitis under the scope.

2) Is it a new patient?  On most new patient exams, you may bill both because the physician is not aware of what is going to need to be done; therefore a complete new patient exam is warranted.


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## jackjones62 (Apr 5, 2016)

Always remember that in Coding there are a lot of gray areas....RELAX; just because there is only "One" diagnosis does not mean you cannot charge for the E/M on the same day; regarding anyone coming in for the first time or an established patient coming in for a new problem or even an established problem, the physician needs to access and evaluate before any decision making is made; with regards to your nose bleed, pt. came in with a history of nosebleeds and is on anticoagulants, and E/M was done and a decision to cauterize was made even though they were not actively bleeding, bill your E/M & cautery, your physician performed it as well as the cauterization; regarding direct laryngoscopies, if someone came in for hoarseness, you cannot anticipate a physician is always going to do a scope, they would perform a mirror exam (indirect laryngoscopy - 31505) 1st (which is billable BTW) and if there was too much of a gag reflex or they thought they needed a better view, a scope would be in order, and yes, bill it..... If, for example a pt. came in for a recheck of their hoarseness and the scope was realistically the only thing needed for the exam, than bill the scope only; if a pt. came in hemorrhaging from the nose, they w/b taken in immediately and taken care of, bill the hemorrhage control only....it comes down to common sense; also, planned procedures - a physician evaluates a pt. and tells them they need a procedure done and books them the following week, bill the procedure only for that scheduled procedure, the E/M has already been done, but, if they were given medication to use for the week and were told to come back for recheck and if no improvement was noted then they would proceed with procedure, bill the recheck E/M and procedure, as long as the E/M was documented; regarding the microscope exam, bill it when it's appropriate, yes, I would bill it for the wick placement, if the physician needed it because they could not place it using otoscope or direct visualization; bill it if the physician needs it to debride an external otitis or access a fungal infection and apply medication, microscope exams and usage are usually performed because the physician cannot access the situation under normal direct visualization. 

Bottom line, I never code anything that I cannot argue and support thru documentation.

Jennifer
IN ENT


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