Otolaryngology Coding Alert

In an office visit, a patient must fail the mirror exam,which is part of your E/M exam, before you can charge separately for flexible laryngoscopy. Just as important is your physician's report as to why the patient needs a flexible scope. If you don't have this information, you won't be able to report the service.

Bottom line: CMS clearly advises you to include the mirror exam (or regular fiberoptic scope) in the E/M, and states that the flexible laryngoscopy is separately billable only if the patient is a child or has undergone a failed mirror exam, says Eileen Blankership, CPC, reimbursement analyst at the University of Oklahoma Health Sciences Center's Department of Orthopedic Surgery and Otolaryngology in Oklahoma City.

Example: A patient comes into your otoloaryngologist's office for an exam complaining that he feels he has something in his throat. The ENT carries out the exam and thinks that the patient needs a flexible laryngoscopy.

What happens: A flexible laryngoscopy employs a thin, flexible endoscope that an otolaryngologist can manipulate to examine areas not normally seen by traditional examination techniques. It is done under direct visualization. Although the image quality is not as good as that obtained by rigid laryngoscopy, most patients undergo flexible laryngoscopy without much difficulty.

In this case, you can bill the E/M service, such as 99213-25 (Office visit for the evaluation and management of an established patient ... Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with the scope (31575, Laryngoscopy, flexible fiberoptic; diagnostic). Why: "The physician does a diagnostic procedure to assist the patient in what might be causing his complaint and what course of treatment to take," explains Melissa Blow, CPC, of St Louis. That's an extra $105.68 you can add to your bottom line (code 31575 contains 2.93 relative value units [RVUs] times current conversion factor of $36.0666).

Keep in mind: Some insurance companies require you to use modifier 25, but if the diagnostic procedure does not have a global period, you don't need to append it. Per CPT, you do not have to have a separate diagnosis for the E/M and procedure.

Pitfall 1: Flexible laryngoscopy is an exam of the larynx. If the physician's documentation gives you an examination of only the nasopharynx, do not go for 31575. Instead, choose 92511 (Nasopharyngoscopy with endoscope [separate procedure]). Otolaryngologists generally agree that you have to pass through the nasopharynx, the pharynx, and supraglottis/hypopharynx to get in position to examine the laryngeal area.

Pitfall 2: A typical source of confusion is when physicians choose to perform a nasal scope insertion for a laryngoscopy because inserting the scope through the patient's nose is easier than making the patient hold his mouth open for a long time, says Tom Colletti, MPAS, PA-C, with Duke Medical Center in Durham, N.C. In this case, the phrase "nasal scope insertion" in your physi- cian's documentation can give you a wrong  reading; you incorrectly might assume that he performed a nasopharyngoscopy instead of a laryngoscopy.