Otolaryngology Coding Alert

Hint: Remembering one thing will point you in the right direction.

Diagnostic endoscopies are some of the most common procedures otolaryngologists perform, so every coder needs to know the differences between types – and which ones are inclusive of the others. If you remember your anatomy, choosing the best codes for each encounter will be a snap.

Procedure 1: Nasal Endoscopy

When the otolaryngologist performs a nasal endoscopy, she looks at the anterior part of the nose. The procedure often involves multiple passes to view the openings into the sinuses, turbinates, and possibly the back of the nose. A rigid endoscope or flexible endoscope can be used to perform a diagnostic nasal scope. Nasal endoscopy is recommended for patients with conditions such as benign neoplasms (210.7, Benign neoplasm of nasopharynx), chronic sinusitis (including diagnoses 473.0, 473.1, 473.2, 473.3, 473.8, 473.9), and acute sinusitis (including 461.0, 461.1, 461.2, 461.3, 461.8, 461.9).

Code it: You should report 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) for a diagnostic nasal endoscopy. Appending modifier 50 (Bilateral procedure) is not necessary (or appropriate) since the descriptor includes both unilateral and bilateral procedures. The physician is paid the same no matter if he performs the service unilaterally or bilaterally by definition in AMA CPT®.

Descriptor note: Remember that the “separate procedure” designation doesn’t mean you always report 31231 in addition to other services. The verbiage actually means that the code is included in any larger procedure code performed on the same structures during the same patient encounter.

Procedure 2: Nasalpharyngoscopy

The physician performs nasalpharyngoscopy to view the patient’s nasal pharynx. The openings to the Eustachian tubes, the adenoids, and the choanae (where the pharynx and nasal passages meet) are also examined. The physician advances a flexible scope through the nose and studies the area extending from the posterior edge of the soft palate to the nasopharyngeal wall, including the eustachian tube openings.

Diagnoses supporting endoscopic nasalpharyngoscopy can include 235.1 (Neoplasm of uncertain behavior of lip oral cavity and pharynx), 527.0 (Glossitis), 381.01 (Acute serous otitis media), 381.81 (Dysfunction of Eustachian tube), and others.

Note that diagnosis 235.1 must come from the pathologist when they cannot differentiate the neoplastic cells. If the physician is not sure what the lesion is, you should report 239.0 (Neoplasm of unspecified nature of digestive system) instead, 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.

Code it: The correct code for endoscopic nasalpharyngoscopy is 92511 (Nasopharyngoscopy with endoscope [separate procedure]). Note the “separate procedure” designation, as with 31231.

Procedure 3: Flexible Fiberoptic Laryngoscopy

Flexible fiberoptic laryngoscopy allows the physician to advance a flexible scope through the nose, past the nasopharynx, pharynx, hypopharynx, and into the larynx. You report this common diagnostic procedure with 31575 (Laryngoscopy, flexible fiberoptic; diagnostic).

Associated diagnoses can include 727.20 (Dysphagia, unspecified), 240.9 (Goiter unspecified), 243 (Congenital hypothyroidism), 464.01 (Acute laryngitis with obstruction), 478.30 (Unspecified paralysis of vocal cords), and others.

Narrow Options for Multiple Procedure Encounters

It’s not uncommon for physicians to perform more than one of these endoscopic procedures during the same patient encounter. You’ll rarely code for more than one procedure, however, because the services represented by the individual codes overlap.

Use these reminders to select the correct code:

• Code 31231 includes the services represented by 92511. You must look at the nose to reach the nasopharynx, so only report 31231. A modifier (such as 59, Distinct procedural service) is never allowed, so the 31231/92511 bundle can never be overridden.
• The services for 31575 include the components of both 31231 and 92511 because the physician must look at the nose and nasopharynx to reach the larynx. If your physician performs 31575, that’s the only code you should normally report.

Check the edits: Correct Coding Initiative (CCI) edits sometimes allow you to report two of the services together if you have clear documentation explaining the reason for using two different endoscopes on the same date of service. For example, the code pair of 31231 and 31575 carries a modifier indicator of “1,” which means you can sometimes append a modifier to 31231 and report both services. The pair of 92511 and 31231, however, has a modifier indicator of “0,” which means you should never append a modifier to break the edit and report both services.

The AAO-HNS convinced CMS to change the CCI modifier indicator from a “0” to a “1” in 2008 for code pair 31231 and 31575. However, CMS had concerns that allowing both codes to be reported could open opportunities for abuse. They do not consider it commonplace to see both flexible laryngoscopies and nasal endoscopy services with a 59 modifier and feel that this will be the exception, not the rule. An article from AAO-HNS regarding the matter specifically states the following:

“CMS will not modify the modifier indicators for these edits continuing to allow use of NCCI-associated modifiers. A provider should NOT report both codes of a code pair edit if the nasal endoscopy can be performed with the same flexible endoscope utilized for the laryngoscopy. However, we understand that there are very occasional circumstances where it is medically reasonable and necessary for a provider to perform the nasal endoscopy with a separate rigid endoscope. In the latter scenario, a provider may report both codes of a code pair edit utilizing an NCCI-associated modifier.”

Result: “It’s very important to keep in mind that overriding this CCI edit can put the practice on CMS’s radar, so should be used very sparingly,” Cobuzzi cautions.

RVU background: CMS revalued the RVUs for these endoscopy codes in 2004. Prior to 2004, 31575 held more RVUs than 31231. As of 2004, however, because 31231 involves multiple passes in the nose, viewing the sinuses and turbinates on both sides, the RVUs were reversed, providing higher RVUs for 31231 than 31575. Right now, in-office RVUs for 2014 for 31231 is 5.92 while 31575 has 3.24 RVUs.

“If the practice submits a claim with both services on it in error, CMS will pay the column 1 code, 31575, or the code with the lower RVUs, with 3.24 RVUs,” Cobuzzi says. “Make sure you submit the CPT® code that has medical necessity supported by the diagnoses.”