Otolaryngology Coding Alert

 Utilize this guidance for the most current coding instructions.

Staying up to date on the most timely and relevant coding instruction is crucial if you want to avoid any snags in the billing process. With a fluid set of CPT^® and ICD-10-CM guidelines incoming at monthly and quarterly intervals (via CPT Assistant and Coding Clinic), you’ve got to stay on top of your game to avoid getting comfortable with outdated guidelines.

When it comes to the reporting of code 31541 (Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope), a set of 2019 CPT^® Assistant articles have added a little bit of recent context that may impact your code reporting.

Have a look at what guidelines have shifted so you’re up-to-date on the latest authoritative guidance on 31541 reporting.

Test Out New Guidelines Using 2 Examples

Example 1: Direct microlaryngoscopy with CO2 laser ablation of subglottic stenosis

CPT^® Assistant (September 2019; Volume 29: Issue 9) advises that you report code 31541 when the surgeon performs a direct microlaryngoscopy with bilateral laser reduction for a vocal cord thickness or mass. However, the diagnostic component plays a crucial role in determining whether 31541 is appropriate. There’s some confusion within the coding community as to whether 31541 may be reported for subglottic stenosis, or if it exclusively pertains to vocal cord lesions, masses, and other related diagnoses.

Fortunately, another recent CPT^® Assistant (July 2019; Volume 29: Issue 7) adds some additional context by touching on a similar diagnostic scenario as the one above. This CPT^® Assistant article advises that you report 31541 for a “CO2 laser excision of subglottic scar band that resulted in stenosis.” If you combine the information you’ve learned from both respective CPT^® Assistant articles, you’ve got everything you need to determine whether you should be coding 31541 or resorting to unlisted code 31599 (Unlisted procedure, larynx) in future scenarios. Since subglottic stenosis is always the result of an underlying condition, most clinical indications should align with the CPT^® Assistant’s description of a vocal cord “thickness or mass.” Scar tissue buildup, for instance, is a clear example of a generalized subglottic pathway thickening described by CPT^® Assistant. Furthermore, whether you’re coding a congenital abnormality, a neoplasm, or another condition obstructing the vocal pathway, it should still meet the criteria for 31541 coding.

If you’re not taking into account CPT^® Assistant guidelines, the example above involving laser ablation to treat subglottic stenosis may not technically meet the criteria for 31541 without further description as to what is causing the stenosis. Furthermore, you’ll find plenty of instances prior to 2019 (on forums and otherwise) of coders advising that a surgical example such as the one above be coded using 31599. Instead, you’ve now got enough guidance to conclude that 31541 meets all the required criteria in this clinical scenario.

Factor in RVUs When Selecting Code to Unbundle

Example 2: Consider a similar surgical scenario where the surgeon initially performs a diagnostic rigid bronchoscopy to confirm no diseased tissue extends beyond the glottis. Next, the surgeon performs a direct microlaryngoscopic ablation of subglottic stenosis that includes a balloon dilation of the glottic area and a Kenalog^® injection in order to soften the scar tissue following ablation.

Refresher: Ronda Tews, CPC, CHC, CCS-P, AAPC Fellow, director of billing and coding compliance at Modernizing Medicine in Boca Raton, Florida emphasizes the importance of understanding the difference between respective services when a bronchoscopy and a laryngoscopy are performed in tandem with one another. “A laryngoscopy examines the the throat, larynx, or vocal cords. A bronchoscopy examines the area involving the airways, which includes the trachea, bronchi and bronchioles,” says Tews. In the example above, the surgeon performs the diagnostic bronchoscopy in order to gauge the extent of area of diseased tissue affected.

Here, you’ve got 31541 as your underlying surgical code for the subglottic ablation, but you’ve got to determine which of the additional performed services may be coded separately. To start, you may opt for code 31571 (Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope) to report the Kenalog^® injection. You should also note that there are no existing NCCI edits in place to prevent 31571 and 31541 from being adding the remaining two surgical codes into the mix for the balloon dilation and the diagnostic bronchoscopy. To start, let’s outline the remaining codes in question. You’ll report the balloon dilation of the glottic area with code 31630 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/ bronchial dilation or closed reduction of fracture). Next, you’ll code the initial diagnostic bronchoscopy using 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)).

When performing a National Correct Coding Initiative (NCCI) edits check on all four combined procedures, you’ll see 31622 is bundled into 31630 with a modifier indicator of “0,” meaning no overriding modifier is allowed. This is consistent with the “separate procedure” status of 31622 as well. Additionally, you’ll see that 31541 is also bundled into 31630 with a modifier indicator of “1.” This means that, although NCCI allows a modifier to override the bundle, no overriding modifier should be reported since these services are performed on the same anatomic site at the same encounter. However, you’ll see that the relative value units (RVUs) are substantially higher for 31541 than they are for 31630. Since NCCI policy now allows you to choose between the respective code with the higher RVU set (as of July 2019), you will opt to remove 31630 from the claim instead of 31541.

In doing so, you’ve also removed the bundling edit placed on 31622, making it eligible to be reported alongside 31541 and 31571. “As a result, you may code 31541, 31571, and 31622 together, but the balloon dilation cannot be included because of bundling with 31541,” advises Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, of CRN Healthcare in Tinton Falls, New Jersey.