Otolaryngology Coding Alert

Get the lowdown on documentation requirements for an E/M or scope following sinus surgery with septoplasty so you don't bundle separately reportable items into the global period.

On Aug. 1, an otolaryngologist performed a septoplasty (30520) with 90 global days, as well as bilateral total ethmoidectomies (31255) and maxillectomy with tissue removal (31267), which have zero global days. See if you can tell what to break out and what to include in the following Aug. 14 office note:

Tobacco use: quit 10 years ago (PFSH-social)

Allergies reviewed - no changes (PFSH-history)

History of present illness: Patient reports ongoing (HPI-duration) "sinus headaches" (HPI-associated signs and symptoms). She denies any purulent rhinorrhea (ROS-ENT) or fevers (ROS-constitutional). She does remind me that she has multiple types of headaches, including migraines, etc. (HPI-severity)

She indicates that she is irrigating 2-3 times per day (HPI-modifying factors).

Physical examination: Anterior rhinoscopy reveals clear nose and midline septum (nose included in septoplasty's global package). Examined endoscopically patient's sinuses, including ethmoid sinuses bilaterally and left maxillary sinus (included in endoscopic exam). The patient's sinus surgery defects are healing nicely. There is no evidence of any infection, bleeding, etc. (findings included in endoscopy).

Question 1: Should the doctor report an E/M service?

The above office note has an expanded problem-focused history (HPI: 4-Extended; ROS: 2-Extended; PFSH: past, social 2-Complete) but no physical examination or medical decision-making that stands separate from the scope's minor included E/M.

"I do not see enough documentation that would substantiate an E/M," says Michelle Logsdon, CPC, CCS-P, PCS, Falcon Practice Management in Toms River, N.J.

"More detail needs to be there to show me that the decision for the procedure was secondary to the actual visit," says Suzan Hvizdash, CPC, CPC-E/M, CPC-ED, medical auditor for the University of Pittsburgh Physicians.

Although the patient mentioned headaches, the physician made no further documentation to support an E/M and gave no treatment, says Ginny McManus, billing manager at BergerHenry ENT Specialty Group in New Jersey. It "looks like the patient returned to the office for a planned scope following sinus surgery." The E/M service does not represent an unrelated E/M service from the surgery that created the global.

Exception: If the otolaryngologist had treated and diagnosed the headaches and documented the medical necessity for the scope so that this portion stood alone (such as on a scope form), he could have gotten credit for the E/M service portion that is unrelated to the septoplasty's (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) 90-day global period.

To indicate that the carved out non-nasal portion is unrelated to 30520's existing global period, you would need to append modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to the office visit code (such as 99212-24, Office or other outpatient visit for the evaluation and management of an established patient - problem-focused history, problem-focused examination; straightforward medical decision making).

Challenge: It is difficult to support the carve-out portion that is unrelated to the postoperative care, and the documentation must be very clear as to what belongs to the postop care and what belongs to the unrelated complaints.

Question 2: Should you code the scope as 31233?

You should use a different endoscopy code (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) than the code you suggest (31233, Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]), which would not occur in the office (place of service 11). "Code 31233 should not be performed after postoperative maxillary sinus surgery because this code requires a puncture or trocar cannulation prior to placing the scope," McManus says.

"The use of 31233 or 31235 to report diagnostic sinus endoscopy performed via an existing and patent opening into the maxillary or sphenoid sinus represents incorrect CPT coding," states the American Academy of Otolaryngology -- Head and Neck Surgery in "Reporting Nasal/Sinus Endoscopy: CPT Codes 31233, 31235" (www.entnet.org/Practice/upload/31233-and-31235-endoscopy.pdf).

When an otolaryngologist performs an endoscopic exam after a maxillectomy (31267, Nasal/sinus endoscopy surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus) to view the interior of maxillary sinuses through existing surgically created patent sinusostomies, you should report only 31231, according to the Academy.

More: Stay tuned for the full answer in next month's Otolaryngology Coding Alert.