Oncology & Hematology Coding Alert

"Some practices routinely perform these procedures on patients who come in with throat cancer [149.0], rectal cancer [154.1] or colon cancer [153.0-153.9], but they forget that they should code these procedures separately," says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a coding consulting firm in Dallas, Ga. Failing to separate these procedures when appropriate translates to about $80 to $130 in lost revenue per instance.

When both the patient visit and the procedure are separately documented and reported, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the E/M code (e.g., 99214-25, level-four established patient office visit) to show payers that the patient evaluation was separate and distinct from the surgical procedure. This is the case even though the surgical procedure will have E/M-type services included in the surgical procedure code. By using modifier -25, practices are telling payers that the E/M service was not a part of the preoperative or postoperative care associated with the surgical procedure.

In general, Parman says, getting paid for both E/M services and these surgical procedures is a matter of course as long as modifier -25 is appended to the E/M visit and the documentation is in order. The key to documentation is the inclusion of a separate procedure note or a separate paragraph in the patient record detailing the procedure, techniques and findings. A procedure note should be a practice-specific document that is completed by the nurse or physician describing a procedure and its result. It should include an area where the physician signs and dates it.

Aside from modifier -25 and documentation, oncology and radiation oncology practices should follow the rules that apply for each procedure as well, Hugh adds.

Proving Medical Necessity for 31575

Laryngoscopy (31575) is a method of direct visualization of the larynx by inserting a laryngoscope through the mouth and hypopharynx. To prove medical necessity, oncology practices should report diagnosis codes related to neoplasms in the throat (e.g., 161.x, Malignant neoplasm of larynx). Without codes such as 161.0 (Glottis), payers will consider the use of a laryngoscope to be a screening exam, rather than for diagnostic purposes.

Also, if a biopsy, removal of a foreign body, or removal of a lesion is performed with 31575, you should report 31576 ( with biopsy), 31577 ( with removal of foreign body), or 31578 ( with removal of lesion).

Nasal endoscopy (92511) is usually performed when symptoms specific to the upper airway need examination, particularly when a nasal speculum examination does not provide a satisfactory diagnosis or when the response to medical management is poor, such as when a patient's condition is not improving or is worsening. Most Medicare carriers consider a nasopharyngoscopy with endoscope medically necessary when performed to evaluate a patient with:

1. suspected adenoid hypertrophy (474.12)
2. recurrent serous otitis media (381.01)
3. chronic serous and/or suppurative otitis media (382.00)
4. suspected eustachian tube dysfunction (381.81)
5. a neck mass of unknown etiology (784.2)
6. nasopharyngeal signs/symptoms in which a physical examination including a nasal speculum exam failed to determine the etiology. These include such symptoms as recurrent epistaxis, throat pain, ear pain/fullness, anosmia (loss of smell), hyposnia (defect in sense of smell), anterior facial pain, nasal crusting, rhinorrhea (thin, watery discharge from the nose), etc.
7. known neoplastic disease of the upper airway 8. acute (462) or chronic pharyngitis (472.1).

Lower gastrointestinal endoscopy (45330) is a technique that involves a special instrument that is inserted into the body rectally, permitting visual inspection, sampling and treatment for problems of the lower gastrointestinal tract. Colonoscopic examination of the lower gastrointestinal tract is indicated and covered for the following conditions:

Separate payment for these procedures applies to new and established patient visits, Parman says.

Note: Coders should check with individual carriers and get all these policies in writing.