READER QUESTIONS: Distinquish Direct and Indirect for Laryngoscopy Codes

Know Method for 31505

Question: What's the difference between indirect and direct laryngoscopy, and how should I code these procedures?

Virginia Subscriber

Answer: Laryngoscopy is a procedure that allows the physician to view the back of the throat, including the "voice box" and vocal cords. The indirect method involves a handheld mirror to view the throat. You report this procedure with 31505 (Laryngoscopy, indirect; diagnostic [separate procedure]).

The direct method involves the use of a fiberoptic scope to view the same structures. The direct method provides better views, and you should look at codes 31520 (Laryngoscopy, direct, with or without tracheoscopy; diagnostic, newborn) or 31525 (Laryngoscopy, direct, with or without tracheoscopy; diagnostic, except newborn), depending on the age of the patient.

Question: While the physician was performing a colon-oscopy on a patient, he noticed a lesion that he marked with an injection of India ink. What is the correct code(s) for this procedure?

Rhode Island Subscriber

Answer: You should report 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection[s], any substance) for the colonoscopy with India ink tattooing.
 
Caveat: Depending on the payer, the claim may be returned minus the India ink reimbursement. Most Medicare intermediaries will reimburse for the injection service above the base colonoscopy code. Some commercial payers, however, may only reimburse for the base colonoscopy code (45378, ... diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).

Course of action: If you have to appeal, deluge the payer with documentation to justify the extra reimbursement for India ink tattooing. Coders have been known to fortify India ink appeals with a separate letter laying out cost estimates for the India ink tattooing, materials and supplies used specifically for the tattooing, and extra nursing time the ink  tattooing required.

Question: I've heard that one good way to find out what's really happening with our facility's denials is to talk personally to a claims handler. What's the best way to do this? Should I write to a specific person, or call?

Texas Subscriber

Answer: If you've double-checked your record keeping and are still having trouble finding the reason for a denial, call the claims handler directly, and try to talk to the same person every time - you'll always have better luck getting information from someone who knows you.

If you can chat with the person and find out about her background - for example, if she has clinical expertise - you'll have an "in" with her and know how to approach the questions you want answered in a collegial way. If she doesn't have a clinical background, you'll know not to talk to her using lingo that she won't understand. But be careful: If a handler doesn't have a clinical background or is new at the job, don't talk down to her, because it will only seem condescending and hurt your chances to glean the information you need.

Once you've talked to someone on the phone, write down her name and number, and follow-up with a letter restating the facts to the intermediary. You'll want to have a paper trail of the conversation, rather than relying on your memory five months down the road.

Question: We treated a developmentally disabled patient in the ED who had fluid in his ear. Because he was uncooperative, the physician gave him general anesthesia so she could clean his ears and perform an exam. During the procedure, the doctor found a ventilation tube full of granulation tissue, which he removed. I'm tempted to report 69210 for this procedure, but that code doesn't seem to encompass all the work.
  
Ohio Subscriber

Answer: You are correct: Reporting 69210 (Removal impacted cerumen, one or both ears) does not truly cover all the work performed. Code 69424 (Ventilating tube removal requiring general anesthesia) is more appropriate in this case, because although the initial reason for the anesthesia was to discover the reason for the fluid, the procedure became a 69424 when the physician determined the tube had to be removed. Just make sure you code the patient's disability in the diagnosis to justify the general anesthesia, and that the documentation overall supports the work you're reporting.

Question: Our facility provided services to a patient after we verified her insurance eligibility, but the insurance company claims the patient is not covered. The employer group didn't pay the patient's premium, but the insurance company didn't have this information when we checked, probably because its rolls weren't up-to-date. Regardless, we're not getting paid. What should I do to make sure the hospital sees payment?

Washington, D.C., Subscriber

Answer: Unfortunately, eligibility verification is not always a guarantee of coverage, no matter how thorough your inquiry. If you aren't satisfied that your call to the insurer will translate into coverage, ask the representative to provide you with an approval number or written documentation of coverage. This strategy gives you leverage to appeal if the insurer denies the claim. If all else fails, though, you may just need to seek payment from the guarantor.

Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.