Otolaryngology Coding Alert

You might need to fight for reimbursement.

You can connect the same diagnosis with both the procedure and the E/M service as long as the documentation supports medical necessity for both, according to CMS rules. However, you will find that it is easier to justify both services if you have different diagnoses for the E/M service and the minor procedure. 

Example: The otolaryngologist performs a comprehensive history, expanded problem focused exam, and the encounter has medical decision making of moderate complexity. During the problem focused exam, the physician indicates in the “Larynx” bullet that there was “inadequate visualization on mirror exam so it was decided to perform a flexible laryngoscopy.” There is also a procedure note that demonstrates that he performed a flexible laryngoscopy and shows the findings from the performance of this diagnostic procedure. The patient came in with complaints of a lump in her throat and the physician does not find anything remarkable on completion of the flexible endoscopy. The final diagnosis is “globus.”  

You would code this service as: 

• 99213-25 with diagnosis 784.99 (Other symptoms involving head and neck) 

• 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) with diagnosis 784.99. 

Note: Diagnosis 784.99 will expand to several more detailed options when you begin coding with ICD-10 in October. These will include R06.5 (Mouth breathing), R06.7 (Sneezing), R06.89 (Other abnormalities of breathing), and R19.6 (Halitosis). 

If the payer does not pay the E/M with the 25 modifier and the procedure (the flexible laryngoscopy) with the single diagnosis, appeal with the notes that the E/M service was a separate and significant identifiable service. We can no longer point to the “decision to perform the scope” as a justification for performing the diagnostic scope, according to CCI. Instead, you need to point out that the E/M service is a “separate significant identifiable E/M and that the physician had no idea what was causing the sensation as demonstrated by the enclosed chart documentation,” which justifies reporting 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). The chart will probably show that additional work may be needed if the patient continues with this sensation.