Otolaryngology Coding Alert

In some cancer or trauma patients, otolaryngologists may perform three endoscopic procedures laryngoscopy, bronchoscopy and esophagoscopy using three different kinds of scopes, collectively referred to as a panendoscopy, or a triple endoscopy. Although panendoscopies are considered standard medical practice in certain situations involving such patients, the national Correct Coding Initiative (CCI) bundles the laryngoscopy (31535, laryngoscopy, direct, operative, with biopsy) to the bronchoscopy (31622, bronchoscopy, [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]).

Both procedures may be billable as long as there is a separate diagnosis for each of the two scopes; and modifier -59 (distinct procedural service) is attached to the laryngoscopy. The esophagoscopy (43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) is not bundled to either of the other two scopes and usually is payable separately.

Why Panendoscopies Are Performed

A panendoscopy typically is performed on patients with a suspected carcinoma or on laryngeal trauma patients. For example, the otolaryngologist may feel an unusual mass while examining the patient and schedule a direct laryngoscopy with biopsy.

After taking the biopsy of the laryngeal carcinoma, the otolaryngologist removes the laryngoscope and inserts a bronchoscope to make sure the pathology hasnt spread to the nearby bronchi. The esophagoscopy is performed for similar reasons because all three scopes visually inspect adjacent anatomic areas.

Patients with laryngeal injury, a less frequent occurrence, also may require panendoscopy. Such injuries may result from gunshot or knife wounds, as well as automobile or other accidents, and can involve either blunt or penetrating trauma, resulting in a crushed larynx, cartilage fracture or soft tissue injuries. Although severe injuries usually have obvious findings, less severe but equally important injuries may present with more subtle signs and symptoms.

For example, hoarseness or a change in the patients voice should alert the physician to the possibility of laryngeal injury. Other symptoms include dysphagia (787.2) and anterior neck pain (723.1). If the patients airway is stable, the otolaryngologist may need to use all three panendoscopy scopes to assess correctly the depth of the patients injuries.

Although many otolaryngologists were trained to perform panendoscopies in such situations, Medicares CCI bundles 31535 as a component of 31622. This edit is unusual; in that a laryngoscopy with biopsy normally would not be considered a component of a bronchoscopy; and because the CCI offers no explanation for its edits, some coding specialists speculate that Medicare believes the scoping function of the laryngoscopy may be performed by the bronchoscopy. There are, however, two problems with this line of reasoning:

1. A bronchoscopy does not include taking a biopsy of the larynx; and
2. Otolaryngologists use different scopes, removing
one and replacing it with the other, to perform the two procedures.

Alternatively, the edit may have been included to avoid payment for what amounts to a screening bronchoscopy because finding a second carcinoma is an extremely infrequent occurrence. This view is bolstered by the fact that the edit is accompanied by a 1 indicator in the CCI, which means both procedures can be billed separately in certain circumstances by attaching modifier
-59 to the 31535. On the other hand, if this logic were applied consistently, the laryngoscopy also should be bundled to the esophagoscopy, which is not the case. Admittedly, however, the esophagoscopy is being performed in an entirely separate anatomic system.

Diagnosis Codes Provide Medical Necessity

Whatever the reason for the edit, it need not always apply. To use modifier -59 appropriately to override it, however, medical necessity for both procedures needs to be documented, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent otolaryngology coding and reimbursement specialist in Lakewood, N.J. Usually, Cobuzzi says, this means linking separate diagnoses to the bronchoscopy and laryngoscopy.

There are many situations where two diagnoses could be documented appropriately. For example, if the patient has chronic obstructive pulmonary disease (COPD) and a nodule on the larynx, the COPD diagnosis would correspond to the bronchoscopy, whereas the 31535 would be linked to the mass.

If the patient does not have a chronic pulmonary disorder but has a sign or symptom such as coughing up blood or hemoptysis (786.3), the bronchoscopy also should be billable separately, as long as the otolaryngologists documentation includes two real, separate studies that result from both procedures. The documentation also should include a statement that indicates that two separate scopes were used to perform the procedures.

In some cases, even a single diagnosis may be sufficient. For example, if the patient has a lesion that involves both the trachea and the larynx, it would be reasonable to bill for both scopes. Again, the documentation would need to reflect carefully that the single lesion affected both areas.

If Diagnosis Relates to Larynx, Bill Laryngoscopy

Unless a lesion actually affects both the larynx and the trachea (or another area viewed via bronchoscopy), one diagnosis alone is likely to result in payment for only one procedure. Many coders believe that if the laryngoscopy includes a biopsy or removal of a foreign body and a separate bronchoscope is used, then both scopes will be paid. There is a strong possibility that one of the procedures (probably the bronchoscopy) will be denied.

If the documentation does not support a second diagnosis or unusual circumstances such as a lesion that covers anatomical areas viewed by both scopes, the next question is: Which procedure actually should be billed?

Normally such a question wouldnt arise because the comprehensive code includes the component code and therefore should be the procedure that is billed. But in the matter of bronchoscopies and laryngoscopies, the issue is more complicated. In some situations, the component code (the laryngoscopy) may be billed because:

1. The diagnosis may apply to the laryngoscopy. For example, if the patient has a palpable mass in the larynx, the diagnosis (either mass in neck code, or after pathology, a neoplasm of some kind) relates to the laryngoscopy with biopsy, not the bronchoscopy.

2. The laryngoscopy with biopsy is a surgical procedure, whereas the bronchoscopy is diagnostic. According to CPT guidelines, when diagnostic and surgical procedures are performed during the same operative session, only the surgical procedure should be billed.

3. The laryngoscopy pays at a slightly higher rate than the bronchoscopy. Although 31535 is bundled into 31622, the 31535 reimburses at a higher rate (31535, 7.29 relative value units [RVUs]; 31622, 6.12 RVUs; the esophagoscopy 43200 has 6.60 RVUs).

Because the diagnosis may relate to the laryngoscopy, which is a surgical procedure that also pays better than the bronchoscopy, it may be hard to understand why Medicare chose 31622 as the comprehensive code. The only plausible answer is that the bronchoscopy goes further and looks deeper in the same anatomic system than the laryngoscope. Still, when the diagnosis relates to the larynx, most coding specialists agree that the laryngoscopy, rather than the bronchoscopy, should be billed.

Esophagoscopies and Separate Procedures

As mentioned previously, the esophagoscopy is not bundled with either the bronchoscopy or laryngoscopy. Therefore, Medicare carriers will pay for it when performed as part of a panendoscopy, and so will most but not all private carriers because the procedure takes place in another anatomic system, unlike the bronchoscopy/laryngoscopy, which are performed at different sites in the same system.

Still, a third diagnosis is preferable to indicate the medical necessity of performing the panendoscopy, says Ann Hughes, CPC, a coder with Mid-Vermont ENT, a three-physician practice in Rutland, Vt. Among the many diagnoses that provide medical necessity for the procedure are difficulty in swallowing, or dysphagia, and gastroesophageal reflux disease, commonly referred to as GERD (530.81).

Otolaryngologists also should note that the esophagoscopy, like the bronchoscopy, is classified as a separate procedure in CPT 2000, which means that the code may be reported by itself, but cannot be billed as a second procedure along with other codes of which it forms a component. In other words, if a general surgeon were to perform an esophagoscopy and then perform an esophageal resection, the esophagoscopy could not be billed.

Similarly, if a pulmonologist performed a bronchoscopy in advance of a more extensive procedure, the bronchoscopy would be included in the primary service.

In the case of a panendoscopy, although other procedures are being performed, the separate procedure status of both the bronchoscopy and the esophagoscopy does not apply because neither the esophagoscopy or the bronchoscopy are components of each other nor the laryngoscopy. The only procedure that might be considered a component, the laryngoscopy, which CCI considers a component of the bronchoscopy, is the only procedure that is not designated as a separate procedure.

Note: Not all commercial carriers adhere strictly to the CCI and some reportedly deny one or more scopes even when the operative session is well documented and a separate diagnosis is provided for each scope. Before the panendoscopy is performed, it is advisable to check with the carrier in question to determine what their policies are in this area. If such a denial occurs despite the otolaryngologists best efforts at documentation and the presence of separate diagnoses, an appeal should be filed.

Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of CPTs editorial panel and executive committee, contributed to this article; as well as Emily Hill, PA-C, of Wilmington, N.C., a member of the AMAs Relative Value Update Committee, Correct Coding Policy Committee and CPT-5 Project; and independent coding and reimbursement specialists Teresa Thompson, CPC, of Sequim, Wash.; Cheryl Odquist, CPC, of San Diego, Calif.; and Susan Callaway-Stradley, CPC, CCS-P, of North Augusta, S.C.