Otolaryngology Coding Alert

How to protect your 9921x-25 pay

If you're billing laryngoscopy with established patient visits, get ready for lots of payer scrutiny.

Increasingly, major payers are asking to review in-office laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic) claims that contain an established patient office visit (99212-99215, Office or other outpatient visit for the E/M of an established patient ...). Even worse, some insurers are requesting automatic E/M repayments.

Here's how to find out if you're a target and what you can do to protect your laryngoscopy pay.

Who's at Risk

You'd better be ready for other payers to follow Indiana and Kentucky Medicare's lead and start questioning the validity of established patient office visits billed with laryngoscopy. "Is anyone receiving requests for insurance reviews from Medicare and Blue Cross for laryngoscopy done in the office?" asks Stephanie Staples, coding specialist at Kentucky Ear, Nose and Throat, which has four otolaryngologists.

Problem: Indiana and Kentucky's Medicare carrier started targeting ENT practices based on 31575 and modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) established E/M visit billing patterns. Administar Federal, Indiana and Kentucky's Part B carrier, is now asking otolaryngologists to repay any established visit reimbursement that they billed in addition to the diagnostic laryngoscopy, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J. "The carrier is assuming the encounters didn't warrant modifier -25."

Out: Each practice in Indiana and Kentucky can appeal the recoupments. Expect plenty of scrutiny if you choose to appeal. The insurer will audit each chart to see if documentation supports using modifier -25, Cobuzzi says. Before you decide to appeal, you must decide whether your documentation supports an established patient E/M with a laryngoscopy.

Which Cases Withstand Scrutiny

Whenever you bill 99212-99215 with 31575, the visit must qualify as a significant, separately identifiable E/M service from the laryngoscopy. Remember, even minor procedures contain a minor related pre- and postoperative E/M, such as prepping the patient and issuing any findings. So to report an established patient E/M in addition to the laryngoscopy, the otolaryngologist must perform a significant, separately identifiable history, examination and medical decision-making from the procedure's.

Key: Documentation must clearly show that the visit meets modifier -25 criteria. Separate chart and procedure notes will help substantiate the E/M from the laryngoscopy.

The chart note should identify the significant, separate E/M. "In the first paragraph, the otolaryngologist should document a history, an exam and the medical decision-making that lead to the decision to perform the scope," Cobuzzi says. He should write the procedure note in a separate paragraph. "This way you can actually draw a line between the E/M and the procedure to show the separate nature of the two services."

Beyond-Scheduled Scope Pre-Op Warrants E/M

Auditors may maintain that the above history, exam and medical decision-making are part of the procedure's preoperative service. "No specific documentation exists as to what the preoperative E/M entails," Cobuzzi says. So, how can you determine if your otolaryngologist's documentation supports a separately identifiable E/M service?

Solution: See if the documented E/M is more than a scheduled laryngoscopy's service includes. Think of what your otolaryngologist would do preoperatively for a scheduled scope, Cobuzzi says. "That is the pre-op E/M." To bill a 99212-99215-25, documentation should show that the otolaryngologist performed much more than a scheduled laryngoscopy's preoperative service.

Tip: Separate diagnoses will also support billing 9921x-25 with 31575. For instance, an established patient presents with a complaint 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 reveals a polyp (478.4, Polyp of vocal cord or larynx). 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 9921x-25 (Office or other outpatient visit for evaluation and management of an established patient ...) in addition to 31575. Link the E/M to 784.49, and link the scope to 478.4.

The visit doesn't have to contain a different diagnosis. "Medicare says you don't need a separate diagnosis to bill 9921x-25," Cobuzzi says. But, two ICD-9 codes help substantiate the E/M's significant and separate nature.

Curb Further Audits

You can help stop payers' 9921x-25 crackdown by monitoring your 31575 use. Medicare started targeting office visits with scopes due to billing patterns that suggested the scope was an integral part of the E/M service. "Some otolaryngologists treat the scope as part of their exam and perform the procedure on every patient," Cobuzzi says. Routine use leads to problematic patterns that trigger audits.

Better way: Your otolaryngologist should reserve laryngoscopy for when the diagnostic tool is medically necessary. The otolaryngology exam should include a mirror exam, not just a scope, so 31575 remains a separate procedure and not an integral part of the exam.

Two E/Ms Escape Investigation

Administar Federal is not targeting new patient visits and consults. Due to the history, evaluation and medical decision-making built into a new patient visit or consult, codes 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) and 99241-99245 (Office consultation for a new or established patient ...) more easily warrant separate billing. The history, examination and medical decision-making that led the otolaryngologist to perform the laryngoscopy is often clearly identifiable as a significant, separate service from the procedure's usual pre-, intra- and postprocedure work.

Note: For more tips on getting 9921x-25 paid with 31575, see November 2003's Otolaryngology Coding Alert's article "4 Tools Improve Your Scope Visit Pay" online at www.osslogin.com/content/oss_admin2/cgi//member_login.cgi?action=view_article&article=44200&keywords=31575. Plus, test your modifier -25 skills with three laryngoscopy chart notes in next month's Otolaryngology Coding Alert.