Otolaryngology Coding Alert

Secret: Larynx versus nasopharynx makes the difference between 31575 and 92511

Don't give up thousands in E/M service or scope pay because you don't know which CPT codes you can report. Instead, nail down the coding best practices -- and snafus to avoid -- when coding in-office flexible laryngoscopy.

Choose 31575, 92511 Based on Anatomy Examined

If you-re not sure how to classify a diagnostic scope in the office, you-re not alone. What CPT code should I use for a flexible laryngoscopy in the office? asks Ken Stein, PA-C, with Hunter & Clark PC, specializing in otolaryngology and facial plastic surgery in Oklahoma City.

Do this: Look at the anatomy that the otolaryngologist examines. Pinpointing whether the exam involved the larynx or the nasopharynx will tell you which flexible laryngoscopy CPT code you should use.

Option 1: If the scope goes all the way down to the larynx and looking at the larynx is medically necessary, you should bill the flexible laryngosocpy using 31575 (Laryngoscopy, flexible fiberoptic; diagnostic), says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Option 2: If, however, the otolaryngologist examines only the nasopharynx, you should report 92511 (Nasopharyngoscopy with endoscope [separate procedure]). Example: A physician may look at the nasopharynx to evaluate eustachian tube dysfunction or a mass in the nasopharynx.

Bill Standalone E/M Using Modifier 25

You-ve decided on 31575 or 92511, but you don't want to leave any charges on the table. -Should I bill the flexible laryngoscopy separately from the general ENT exam?- Stein asks.

Action: You should bill both the diagnostic scope and an E/M service when two requirements are met. The exam:

1. does not include the elements of the findings of the scope

2. stands on its own.

Look for Separate HEM

-How can I identify a standalone E/M service?- you ask. The chart notes must describe a history, examination and medical decision-making that is significant and separately identifiable from the scope, Cobuzzi says. To bill an E/M service in addition to a scope, the office visit or consultation must qualify for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Prowl for 2 E/M Circumstances

CMS further limits the opportunities to report an E/M service in addition to 31575 and 92511. The National Correct Coding Initiative (NCCI) version 7.2 introductory language added a minor related E/M service to all procedures that contain XXX global days. That means the -laryngoscopy and nasopharyngoscopy both include a small E/M service,- Cobuzzi says.

Impact: An E/M service only qualifies for separate reporting from a diagnostic scope when the office visit or consultation is for:

1. a different reason from the scope

2. the decision to perform the procedure.

Don't forget: The otolaryngologist's documentation must reflect the above circumstances. He should use a separate procedure note for the scope to visually indicate its significant separateness from the E/M service.

Tally Your HEM

You-ve penciled in your scope procedure code. Now you need to weigh your possible charges.

Step 1: Choose the E/M code based on the standalone HEM portions. Be careful: When you calculate the examination level -- problem-focused, expanded problem-focused, detailed or comprehensive -- do not include the findings of your scope if you are billing it separately, Cobuzzi says. But if the otolaryngologist documents that he could not adequately visualize on mirror exam the laryngeal and/or nasopharyngeal areas and documents those findings, he should receive credit for those bullets.

Jump to -High- for Risk Exception

When you factor the level of medical decision-making, watch for circumstances that may raise the risk factor for undergoing a flexible laryngoscopy or nasopharyngoscopy. The Risk of Complications and/or Morbidity or Mortality section of the 1997 Documentation Guidelines for E&M services classifies -diagnostic endoscopies with no identified risk factors- as -moderate- risk, says Jamie Kurrasch, CPC, at Primary Care Partners PC in Grand Junction, Colo. But -diagnostic endoscopies with identified risk factors- are listed as -high- risk.

Warning: Don't increase the risk factor just because the patient's undergoing a scope. -Does the fact that an endoscope procedure has risks associated with it make it a -high- level for a diagnostic procedure ordered, or wouldthe patient need to have a medical issue such as a recent heart attack to make it a -high- level?- Kurrasch asks.
  
Do this: You should usually give an otolaryngologist moderate risk credit for ordering a scope. -All patients undergoing an endoscopy face a certain amount of risk, so the ordering of the endoscopy is always the same,- says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Exception: If a patient has an underlying health condition, such as a recent heart attack, that makes his service more questionable, you should increase the risk factor from -moderate- to -high,- Callaway says. Because the risk for that patient is increased, you should give the physician credit for -high- risk to represent ordering a diagnostic endoscopy for a patient who has identified risk factors.

Opt for 1 Code Using These RVUs

Step 2: If you-re debating whether you code the E/M service instead of the scope, consider these values published in the 2007 National Physician Fee Schedule:

- On the new patient side, only 99205 (4.93) has more RVUs than 92511 (4.08). The visit would have to qualify for 99204 (3.92) to outvalue 31575 (3.01).

- For an established patient office visit, only 99215 (3.42) has more RVUs than 31575. Code 92511 has more RVUs than any established patient office visit code.

- If the visit qualifies as a consultation, 99243-99245 (3.42-6.26) contain more RVUs than 31575. And 99244 (5.04) and 99245 (6.26) have more RVUs than 92511.