Otolaryngology Coding Alert

How to combat a key ENT problem

You can get payers to cover diagnostic scopes, such as nasopharyngoscopy, nasal endoscopy and laryngoscopy, with an E/M service. Just make sure that the visit warrants modifier -25, the documentation supports a separate service, and the insurer doesn't impose frequency restrictions, coding experts say.

Getting payers to cover nasal endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) with an office visit (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) is one of the biggest problems for Margie Gittelman, office manager at Paul Gittelman, MD, FACS, in Mamaroneck, N.Y. "Some insurers, such as Cigna, will pay after I write an appeal letter," she says.
 
Many third-party payers don't want to pay for both an office visit and a scope, says Teresa Thompson, CPC, CCC, a nationally recognized speaker on otolaryngology coding, compliance and reimbursement and president of TM Consulting in Carlsburg, Wash.

Don't give up, Thompson says. To combat E/M-scope denials, coding experts offer the following four tips:

1. Know What Justifies Modifier -25

First, make sure that the office visit is separately reportable, Thompson says. Remember: Just because you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to an E/M service doesn't justify its use.

The National Correct Coding Initiative includes a related pre- and postoperative E/M with codes that contain zero global days, such as 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). Therefore, you should only report an office visit that qualifies as a significant, separately identifiable service from the scope.

For instance, a new patient complains of hoarseness (784.49). The otolaryngologist performs and documents a history, examination and medical decision-making. Based on his findings, he decides a laryngoscopy is necessary and separately documents the procedure. The scope doesn't reveal any problems, such as a polyp (478.4, Polyp of vocal cord or larynx). But, because the otolaryngologist performed a separate history, examination and medical decision-making from that included in the laryngoscopy, the visit meets modifier -25's definition. Therefore, you should report 9920x-25 (Office or other outpatient visit for the E/M of a new patient ...) in addition to 31575.

2. Get Your ENT to Write Separate Notes

You should also encourage your otolaryngologist to document the exam and scope on different pages, Thompson says. To show payers that the E/M service led to the diagnostic procedure, encourage your otolaryngologist to write the history, examination and medical decision-making on page one under the examination note. He should then detail the reason for the scope as well as all associated findings on page two in the procedure note.

Physically separating the service and procedure will support the E/M service's separately identifiable nature. For instance, an internist requests an otolaryngologist's opinion on a patient who has a long history of unresolved laryngitis (476.0, Chronic laryngitis). On page one, the otolaryngologist records the patient's past family and social history, his exam results including noting that the patient's gag reflex prevented him from fully visualizing the patient's larynx with a mirror, and a recommendation that the patient have a laryngoscopy. The otolaryngologist then notes his laryngoscopy findings, such as "Both vocal cords move well and approximate in the middle line ...," on page two under the procedure heading. Using separate pages allows a nonmedical reviewer to easily spot the separate E/M service, Thompson says.

3. Show Compelling Reason for Scope

The main reason payers get away with denying scopes is that documentation doesn't show why a mirror exam was insufficient, Thompson says. Because otolaryngologists are increasingly using flexible laryngoscopy and mirror exam interchangeably, more and more carriers are bundling 31575 to any accompanying E/M service provided on the same date of service, she says.

For example, in its policy statement regarding 31575, the American Academy of Otolaryngology - Head and Neck Surgery states, "Flexible laryngoscopy should not be considered a routine part of the initial visit." In other words, your physician shouldn't use flexible laryngoscopy simply as a replacement for the mirror or routinely perform it on every patient.

An otolaryngologist may perform a flexible laryngoscopy because the scope can examine areas that are inaccessible with the mirror or because the patient cannot tolerate the mirror due to a strong gag reflex. Your otolaryngologist has to document why she resorted to the laryngoscope.

To do this, encourage her to document that she attempted to do a larynx mirror exam before using the scope. A note that such as "I couldn't visualize larynx with mirror, so I used a scope" will help you successfully appeal denials, Thompson says.
 
4. Check Your Carriers' Limits

 Even though scopes contain zero global days, some private payers are imposing frequency limits. "Health Net, a managed healthcare company in the Northeast, will cover nasal endoscopy once every 90 days," Gittelman says. If you don't pay attention to these carrier-imposed limits, you'll never get paid, she says.