Otolaryngology Coding Alert

Tip: Document pain level as part of ROS.

A recent “Part B Ask the Contractor” teleconference hosted by reps from Part B MAC National Government Services (NGS) answered a wide range of questions, including several of interest to otolaryngology practices. Read on for three Q&As from the call that can help you avoid some coding pitfalls. 

Question 1: What Constitutes Risk Factors? 

A Part B practice asked the NGS experts what the MAC considers “risk factors” under “risk management” in the MDM. “Is it comorbidity? Or complications associated with the surgery?” the practice asked.

“There are a wide variety of risk factors that we consider,” NGS reps replied. “I won’t be able to capture all of them here, but they certainly include comorbidities, patient age, complications associated with that surgery, prior problems the patient had with anesthesia, patient weight, other complications the beneficiary may have experienced with prior surgeries, and others we aren’t capturing, but it certainly goes beyond comorbidity when we’re thinking about risk management in terms of surgery.”

“The answer is sort of ‘all of the above,’” added NGS Medical Director Laurence Clark, MD, “because if you think about it clinically, you’re fitting an individual’s own unique risk factors into the expected cardiovascular, endocrine, physiologic demands of the surgical procedure itself.”

Question 2: Can ‘Pain Level’ Be Used Twice?

Another caller to the forum asked whether the pain level documented in the exam could also be used under “constitutional” in the review of systems (ROS).

“Yes, if you have a pain level that the patient states during the ROS, you can use that as the pain level documented in the exam,” the NGS rep said. “The medical directors concurred that this would be admissible.” You should also include some general constitutional language such as the temperature, etc., she added.

Another tip: Repeat the pain level that is included in the HPI Severity or ROS of the history in the exam under “constitutional” to ensure the above advice was provided. There is a chance that the medical directors concurred, but the auditor might not treat the record that way. Rather than potentially fight an audit result, you’re better off counting the pain level under “constitutional” and not have to worry about questioning later. 

Question 3: Where Is National X{EPSU} Guidance?

Some Part B MACs have offered a few examples to explain how to properly use the new X{EPSU} modifiers, but CMS itself is still tight-lipped on the subject, which has frustrated many practices looking for guidance.

“CMS is working on additional guidance regarding those modifiers, as well as examples, and more definitive specifications on when to use those modifiers,” said NGS’s Andrea Freibauer during the call. “So, at this point in time, you can use those X modifiers. However, you can still feel free to use the 59 modifier (Distinct procedural service) as appropriate. And as soon as CMS publishes additional clarification and information, we will be getting it out to you in the provider community.”

Currently, all of the X modifiers “have the same exact editing specifications as the 59,” Freibauer said. “If you aren’t comfortable using the X modifiers yet, it is absolutely fine to use the 59.”

Example: The physician performs a nasal endoscopy at 10 a.m. The patient goes to the ER at 8 p.m. that evening with severe epistaxis, so the doctor uses complex techniques to control the anterior epistaxis. The diagnostic endoscopy is bundled with the control of epistaxis but they were done at different times. You can submit the claim for the second encounter with either modifier 59 or modifier XE (Separate encounter).