Otolaryngology Coding Alert

Tip: Verify that your billing can support two true services.

CCI version 19.2 that just went into effect July 1, 2013, adds more layers to further complicate when an otolaryngologist reports the use of an E/M service with minor procedures, specifically when you include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). 

Heads up: This newest update to CCI bundled most E/M codes with most of the minor ENT procedures.

“This makes it appear that CCI did not adequately trust this new verbiage that they added in January of 2013 to quell the use of E/M services with minor procedures, so they decided to create an outright bundle,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. (See “Get the Lowdown on Reporting Minor Procedure With E/M and -25” for more on this verbiage change.)

The bundle has a modifier indicator of “1,” which means you can append a modifier to the E/M code and override the bundle. In most cases for an otolaryngology practice, for example, a 25 modifier would be the appropriate choice to override the bundling of an E/M and a minor procedure when the 25 modifier applies. 

“In other words, these added bundles really do not change the parameters as they were established on January 1, 2013, but they are putting them in bold and making the use of an E/M with a minor procedure really take work and forethought,” Cobuzzi explains. 

Take note: A scope (such as 31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) is a minor procedure that often is reported in conjunction with an E/M code and modifier 25. You might come out ahead by leaving the E/M off the claim. “I think that it is important that you don’t bill an E/M every time you code a scope,” Cobuzzi says. “The payer is going to think that, as described above, the E/M is just the decision to perform the scope and therefore should not be billed separately.”

Example 1:  A patient comes in complaining of a headache and nasal congestion. The physician documents a detailed history and detailed exam. During the exam, it was noted that the otolaryngologist was unable to get full visualization with the nasal spectulum and it was decided to perform a nasal endoscopy. The procedure note indicates that frank pus is noted and that the patient has an acute sinus infection. A culture was taken to send to pathology to identify the bacteria. An antibiotic was prescribed and may be changed when the culture results are received, based on the findings of the pathologist.

In this case, you should be able to code the E/M service with a 25 modifier. Diagnoses for the headache (784.0, Headache) as well as nasal congestion (478.19, Other disease of nasal cavity and sinuses) would be associated with the modified E/M.  The nasal endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) would also be coded with an ICD9 of 461.9 (Acute sinusitis unspecified). 

Example 2: Patient 2 came in to the office complaining of dysphagia. After documenting a detailed history and a detailed exam, the doctor also states that she cannot adequately visualize the larynx and is therefore deciding to perform a laryngoscopy. The procedure note for the laryngoscopy indicates that the patient has dysphagia, oropharyngeal phase. 

In this case, you cannot justify a significant and separately identifiable E/M service, so only 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) and diagnosis 787.22 (Dysphagia, oropharyngeal phase) would be coded.

Keep in mind: These CCI edit rules only apply to payers that follow CCI, including Medicare and state Medicaid payers. Some private commercial payers follow CCI, which means you would need to follow these rules for those claims as well. If a payer does not use CCI for their bundling rules, however, you can then follow the AMA CPT^® guidelines.

“However, it is difficult for physicians and coders to switch back and forth depending on who the payer is,” Cobuzzi says. “It is therefore recommended to follow the most stringent policy for when you can bill an E/M with a minor procedure with a 25 modifier from a compliance perspective. Based on that conservative advice, this would mean following the CCI guidelines and bundling rules.”