Otolaryngology Coding Alert

When the ENT uses the same flexible scope to view the nasal passages, nasopharynx,and/or the larynx, making the correct endoscopy code choice is not always clear cut.

Given that the three diagnostic scopes described above are bundled together, the task of choosing only one becomes even more difficult. Boost your endoscopy coding skills -- and save yourself from attracting audits -- with these five expert pointers.

Zero in on the correct code by checking the procedure note for the anatomic areas that the ENT examined, says Sanford Archer, MD, FACS, professor in the division of otolaryngology - head and neck surgery at the  University of Kentucky College of Medicine in Lexington. Base your code choice, says Archer, on the following:

• If the note discusses only nasal/sinus anatomy, 31231 (Nasal endoscopy,diagnostic, unilateral or bilateral [separate procedure]) is appropriate.
• If the nasopharynx is included in the description, 92511 (Nasopharyngoscopy with endoscope [separate procedure]) is correct.
• If the scope goes beyond the nasopharynx and the ENT visualizes the larynx,31575 (Laryngoscopy, flexible fiberoptic; diagnostic) is appropriate.

Clue: "The standard answer for proper billing of these endoscopic codes is that you code the scope that 'goes' the furthest," Archer comments.

Example: If the ENT examines the larynx with a flexible scope, the correct code is 31575 even if the examiner inspected the nasal cavity and nasopharynx on the way down. If the ENT examines "the torus tubaris because of a chronic serous effusion (381.1x, Chronic serous otitis media) in an adult or evaluation of the adenoid pad in a child, 92511 is appropriate, without respect to what is seen in the nasal cavities," Archer explains.

If the examiner finds a problem further down than he had initially planned to examine, reconsider the code choice. For instance, if the ENT intends to perform a nasal endoscopy (31231) and then sees a nasopharyngeal mass that prompts him to pass the scope to the nasopharynx, 92511 is the correct coding choice, Archer says.

Twist: If, in the case above, the mass blocks the nasopharynx and, thus, the ENT performs only a nasoendoscopy, then 31231 would remain the appropriate code choice, says Archer.

To further clarify the correct endoscopy coding choice, check to see which procedure is medically indicated. "An appropriate diagnosis must support the procedure," Archer says.

Examine the procedure note for the chief complaint, or the reason why the ENT chose to perform the endoscopy, advises Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of N.J.-based CRN Healthcare Solutions. The following examples, says Cobuzzi, help distinguish which diagnoses are appropriate for each procedure:

• If the diagnosis is eustachian tube dysfunction (381.81), medical necessity would support 92511.
• If the ENT looks at the larynx for suspected postnasal drip (784.91), 31575 is the correct choice.
• In the case of chronic sinusitis (473.x), 31231 would be appropriate.

Curve ball: Sometimes the diagnosis may fit with more than one procedure. For instance, if the ENT performs an endoscopy for epistaxis (784.7), says Archer, then either 31231 or 92511 could be appropriate based on the findings (where the bleeding originates). In this case, stick with 31231 or 92511 even if the op notes comment on the larynx but list no larynx-appropriate diagnosis (such as hoarseness [784.49]), advises Archer.

For instances that may merit breaking the endoscopy bundle, look to the sidebar in this issue "Stay in Line with CCI Endoscopy Bundles."

3: Weigh Whether 31231 Fits the Bill

While the inclination may be to code 31231 for highest reimbursement, prudence is warranted to avoid overcoding the service.

Code 31231 carries 4.83 relative value units (RVUs) ($174.29) versus 4.09 RVUs ($147.59) for 92511 and 3.00 RVUs ($108.25) for 31575, according to the 2010 Medicare Physician Fee Schedule and national rate.  (Note: This valuation system is counterintuitive since the endoscopy code's RVUs decrease the further the scope explores.) You must document clear medical necessity to avoid scrutiny when reporting 31231, comments Cobuzzi.

Example: "A patient with sinus symptoms and/or findings that warrant endoscopy because (1) anterior rhinoscopy with decongestion of the nasal membranes does not provide an adequate evaluation, and (2) [the ENT anticipates] that performing the nasal endoscopy may provide significant insight that will affect treatment" would meet the medical necessity criteria for a nasal endoscopy, says Stephen R. Levinson, MD, otolaryngologist and coding consultant based in Easton, Conn.

Another scenario that would support necessity for 31231 is "pre-operative planning for a patient who has radiographic evidence of clinically significant chronic sinusitis (473.x) following maximal medical therapy, and anterior rhinoscopy does not reveal significant intranasal pathology," Levinson adds.

Flipside: A nasal endoscopy is not indicated "when there is no documented medical necessity for such an examination and/or when anterior rhinoscopy provides an adequate evaluation to determine diagnosis and appropriate therapy," Levinson continues.

Furthermore, coding 31231 would not be appropriate if the procedure notes do not include documentation of a complete sinus exam of the nasal cavity, turbinates, meati, and sphenoethmoidal recess, says Jean Acevedo, LHRM, CPC, CHC, CENTC, president of Acevedo Consulting in Delray Beach, Fla.

You may question what to do when the endoscopy turns up no definitive diagnosis.

"It is not uncommon for the scope to come up negative without findings to support the suspected condition," remarks Acevedo. "In that case, coding guidelines require that we code the patient's presenting symptoms."

Example: The ENT may determine that a certain type of headache (784.0, Headache), for which no etiology is found on anterior rhinoscopy or radiographs, might warrant a nasal endoscopy, explains Levinson. The insurer's software will likely be programmed, however, to deny such a claim on the basis that not every patient with a symptom of headache warrants a diagnostic nasal endoscopy, Levinson points out.

What to do: Since private insurers might not honor this diagnosis coding and you may have to appeal for payment, make sure the chart explains the medical necessity for the scope. Provide meticulous documentation and include a listing of reasonable "rule-out" diagnoses in the chart, such as listing possible or suspected sinus infection, to support such a claim, Levinson advises. While "rule-out" diagnoses help justify medical necessity in the chart, on the claim form you must report a definitive diagnosis (or presenting symptoms), not a "ruleout" diagnosis, says Cobuzzi.

If you are also reporting an E/M service (such as 99201-99215, Office or Other Outpatient Services) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the  same day of a procedure or other service) for the encounter, do not include the endoscopy findings in the exam section of the E/M service, says Cobuzzi. The E/M service must be separately identifiable from the scope procedure.

Instead, include the findings from the manual inspection, such as rhinoscopy for the nose or indirect mirror exam for the hypopharynx and larynx, in the E/Mexam note. The notation might only be "visualization is not sufficient on manual inspection."