Otolaryngology Coding Alert

You must not overlook signs and symptoms in documentation.

When a patient presents with signs and symptoms indicative of thyroid dysfunction, the otolaryngologist would likely order a thyroid function study to determine the presence or absence of hormonal abnormalities. However, the provider should not perform these tests without the presence of at least some supporting signs and symptoms of hypothyroidism, hyperthyroidism or thyroid cyst. The otolaryngologist should suspect a thyroid disease only if an aspect of a patient's condition could be accounted for by this disease.

Documenting the appropriate signs and symptoms means a lot to get your billing on the right track. But the whole process should not end there. While keeping your coding proficiency at par can be a real challenge, you can rise above it if you stick to these two basic guidelines.

1. Ensure Medical Necessity of the Test

CPT® guidelines affirms that thyroid function testing is medically necessary in patients with disease and neoplasm of the thyroid and other endocrine glands, metabolic disorders including malnutrition, hyperlipidemia, certain types of anemia, psychosis and nonpsychotic personality disorders, ophthalmologic disorders, various cardiac arrhythmias, disorders of menstruation, skin conditions, patients receiving amiodarone, and myalgias.

A wide array of signs and symptoms, such as tachycardia (785.0), bradycardia (427.89), tremor (781.0), fine or thick skin (782.8), excessive sweating (780.8), weight changes (783.1/783.21), bowel changes (787.99), eyelid edema (374.82), exophthalmos (376.30), hearing loss (389.9), and personality changes (310.1) also classify as proof of medical necessity for thyroid function testing.

For diagnosis and follow-up of patients with thyroid disorders, you might order the the following thyroid function study codes:

• 84436 -- Thyroxine, total
• 84439 -- Thyroxine, free
• 84443 -- Thyroid stimulating hormone (TSH)
• 84479 -- Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR).

Must: The ordering physician must specify in the patient's clinical record that she evaluated the patient's history and physical findings before she requested the thyroid function test. Also, documentation must detail the sign and symptoms which called for the function testing or ongoing medical treatment where thyroid monitoring is appropriate.

Limitation: Most payers cover thyroid function testing up to two times a year in clinically stable patients. However, more frequent testing may be permitted for patients whose thyroid therapy has been altered, or in whom symptoms or signs of hyperthyroidism are noted.

2. Pay Attention To Your ICD-9 Subcategories

Thyroid diseases attack the thyroid gland, located at the base of the neck, which releases hormones that regulate all aspects of metabolism. If this gland does not function properly, a patient could develop any of the following disorders, according to a February 2011 article of For the Record Magazine (Vol. 23 No. 3 P. 27), titled Coding For Thyroid Diseases:

• Hypothyroidism (244) which occurs if the thyroid does not produce enough hormones. When coding 244, be on the lookout for a fourth digit, which is required to identify the specific type of hypothyroidism (i.e., 244.0, Postsurgical hypothyroidism; 244.1, Other postablative hypothyroidism, including hypothyroidism following therapy such as irradiation; 244.2, Iodine hypothyroidism; 244.3, Other  iatrogenic hypothyroidism; 244.8, Other specified acquired hypothyroidism, including secondary hypothyroidism; and 244.9, Unspecified acquired hypothyroidism).

• Hyperthyroidism (242), wherein the thyroid gland makes too much thyroid hormone. The condition is sometimes referred to as an "overactive thyroid." Subcategories of 242 require a fourth digit to identify the specific type of this disease (i.e., 242.0, Toxic diffuse goiter, including Basedow's disease,Exophthamic or toxic goiter, Graves' disease, and primary thyroid hyperplasia; 242.1, Toxic uninodular goiter; 242.2, Toxic multinodular goiter; 242.3, Toxic nodular goiter, unspecified; 242.4, Thyrotoxicosis from ectopic thyroid nodule; 242.8, Thyrotoxicosis of other specified origin; and 242.9, Thyrotoxicosis without mention of goiter or other cause). You would consider a fifth digit subclassification to differentiate the presence/absence of thyrotoxic crisis (e.g., 242.x0 means "without mention of thyrotoxic crisis or storm").

• Thyroid goiter, which include nontoxic nodular goiter (241) and simple and unspecified goiter (240)

• Graves' disease (242.0x), the most common form of hyperthyroidism, which pertains to an autoimmune disorder in which the immune system attacks the thyroid gland and causes it to overproduce thyroxine.

• Hashimoto's disease (245.2) causes inflammation of the thyroid gland and often leads to hypothyroidism.

Example: An otolaryngologist performs a level-four E/M, and orders TSH and thyroid hormone uptake for a patient suspected of a thyroid disease. In her physician's progress note, the otolaryngologist describes the following:

• Objective: Labs done; electrolytes were normal; TSH was minimally elevated;
• Diagnosis: Subclinical hypothyroidism;
• Plan: Follow up in three months, CMP, CBC, and TSH.

Code it: You would define 'subclinical' as 'without clinical manifestations.' This refers to a condition's early stage(s) " before symptoms and signs become apparent or detectable by clinical examination or laboratory tests. Thus, on the claim you should report:

• 99214 (Office or other outpatient visit for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M;
• 84443 and 84479 for the thyroid function tests if they were performed in an office lab;
• 244.9 linked to the CPT®s to indicate the primary reason for the encounter.

If a laboratory technician performed the technical aspects of the service, and theotolaryngologist only interpreted the results and wrote a report, you would only bill the lab report interpretation as part of the E/M medical decision making component.