Otolaryngology Coding Alert

Here's what documentation you need to prove the scope is medically necessary.

If you're uncertain when you should report scope code 31575, then check out these details that will open the door to submitting this code to payers.

Problem 1: You Want To Report 31575 and E/M service.

If a payer bundles laryngoscopy into a same-day E/M service, documentation that shows why a mirror exam (included in the E/M service) of the larynx and surrounding structures was insufficient will help you overturn the EOB determination.

Educate your ENTs on the importance of including this information, presented by Barbara J. Cobuzzi, MBA, CPC, CPCH, CPC-P, CENTC, CHCC, president of N.J.-based CRN Healthcare Solutions. Medically necessary reasons that support performing 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) include but are not limited to:

• macroglossia preventing mirror examination
• gag reflex preventing mirror examination
• trismus preventing mirror examination
• patient unable to cooperate to allow mirror examination due to age (such as infants) or mental condition (mental retardation, dementia, etc.)
• hoarseness, dysphasia, aspiration not clearly evaluated by indirect laryngoscopy
• lesion identified by mirror examination needing further evaluation
• anterior commissure not completely visualized by mirror examination
• aspiration suspected that cannot be evaluated by mirror examination
• evaluation of the larynx and immediate subglottis in patients for tracheal decannulation
• acute airway obstruction evaluation.

Remember: Using a mirror (31505, Laryngoscopy, indirect; diagnostic [separate procedure]) to perform an exam of the throat, oropharynx, etc., is part of the E/M service, based on the 1997 E/M guidelines.

Problem 2: You Don't Know What Dx Supports 31575.

Medical policies differ regarding diagnoses that support performing 31575. But some indications for 31575 may be:

• airway obstruction (chronic, 496; NEC, 519.8)
• aspiration, chronic (507.0, Pneumonitis due to inhalation of food or vomitus)
• cough, chronic (786.2)
• dysphagia (787.2x [requires 5th digit as of Oct. 1, 2007])
• dyspnea (786.09)
• foreign body (933.1, larynx)
• head and neck mass (784.2)
• hemoptysis (786.3)
• history of tobacco use (V15.82)
• hoarseness, chronic (784.49)
• laryngeal trauma (959.09)
• neoplasm, suspected
• obstructive sleep apnea (OSA) severe snoring (327.23)
• otalgia (388.70)
• stridor (786.1)
• throat pain (784.1).

You may use the ICD-9 code associated with the indication for the E/M service (such as 99201-99215, Office or other outpatient visit ...) and, when available, link the definitive diagnosis to the scope (31575) to help show medical necessity.

Example: An established patient presents complaining of hoarseness (784.42). The otolaryngologist performs and documents a history, exam 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, exam and medical decision-making from that included in the laryngoscopy, the visit meets modifier 25's definition (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

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 784.42, and link the scope to 478.4. "You don't technically 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.

Error averted: The otolaryngologist should not include any of his laryngoscopy findings in the exam. He should choose a reasonable E/M level in which none of the larynx exam's content goes into the E/M's exam, Cobuzzi says. "There should be no double counting. Each exam must stand on its own," she says. However, if the physician documents the failed attempt to exam the larynx and surrounding structures in the exam and also documents the decision to perform the flexible scope, you could count the bullets for the failed attempts in the exam -- separate from the laryngoscopy note.