Otolaryngology Coding Alert

Coding diagnostic nasal endoscopy can prove a challenge, considering a handful of codes cover this procedure:

31231 nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)

31233 nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)

31235 nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium)

31575 laryngoscopy, flexible fiberoptic; diagnostic

92511 nasopharyngoscopy with endoscope (separate procedure).

Note: Codes 31233 and 31235 describe more extensive endoscopies (involving sinusoscopy) than the endoscopies described in the other three codes.
 
An even greater challenge presents itself when the coder reviewing 31231, 31575 and 92511 finds that 1) all three codes describe diagnostic nasal endoscopies, 2) the procedures described in all three codes may be performed using the same type of scope, 3) the three codes are not grouped in the same section of the CPT manual and 4) each code has been assigned different RVU ratings.
 
To make coding easier, you need only consider what and where the otolaryngologist performed and the documented reason for the procedure.
 
The difference between nasal endoscopy and nasopharyngoscopy is simple" from a clinical standpoint. If you use a scope and look at the nasopharynx that's nasopharyngoscopy. If however you evaluate all of the nasal cavity including where the sinuses drain that's a nasal endoscopy " says Lee Eisenberg MD an otolaryngologist in private practice in Englewood N.J. and a member of CPT's Editorial Panel and Executive Committee.
 
Medicare carrier local medical review policies (LMRP) often tell otolaryngologists the same thing. For example the LMRP from Empire Medicare Services (Part B carrier in New Jersey and parts of New York) states that 31231 should be used "to report a diagnostic nasal endoscopy when studying the area extending from the nostrils to the posterior edge of the soft palate." The LMRP then instructs otolaryngologists not to use 31231 "to report a diagnostic endoscopy of the nasopharynx. CPT procedure code 92511 should be used when studying the area extending from the posterior edge of the soft palate to the nasopharyngeal wall including the Eustachian tube openings."
 
The diagnostic endoscopy is a more extensive procedure than a nasopharyngoscopy which is why it is assigned about 50 percent more RVUs notes Andrew Borden CPC CCS-P CMA reimbursement manager for the Department of Otolaryngology at the Medical College of Wisconsin in Milwaukee. "Nasopharyngoscopy does not involve looking at the anterior portion of the nose but rather using a flexible scope to look at the eustachian tubes adenoids and choanae (where the pharynx and the nasal passages meet at the end of the hard palate) all of which are located around the nasopharynx " he says. In comparison he notes a diagnostic nasal endoscopy often requires multiple passes to examine the meatus turbinates and openings to the sinus cavities.

Although the distinction between nasopharyngoscopy and nasal endoscopy seems clear the situation becomes considerably more difficult if for example the otolaryngologist performing a nasopharyngoscopy examines the patient's nose. "Otolaryngologists always look at the nose when they scope the nasopharynx just to make sure everything is all right but that doesn't mean you get to bill for 31231 " Eisenberg says. "You need a diagnosis to explain why the nasal evaluation was medically necessary. If it isn't there you can't bill 31231." While many diagnoses justify both 92511 and 31231 474.12 (hypertrophy of adenoids alone) provides medical necessity for 92511 but not 31231 according to the LMRP from First Coast Service Options (Part B carrier in Florida). If the otolaryngologist scoping the nasopharynx for adenoidal hypertrophy alone examines the nose for example the carrier is likely to accept 92511 but not 31231 Eisenberg says.
 
Otolaryngologists may encounter problems obtaining payment for 92511. For example First Coast does not permit nasopharyngoscopy to be performed on a patient with a chronic condition such as otitis media "at each patient encounter" unless the symptoms are not improving or are getting worse. Furthermore some carriers may not accept 92511 with diagnoses like 381.01 (acute serous otitis media). However Eisenberg says when a patient has unilateral middle ear effusion the nasopharynx must be looked at to rule out a pharyngeal tumor if there is no obvious reason for the effusion. Since rule-out diagnoses may not be used 92511 may be denied. In such cases Eisenberg recommends filing an appeal that includes an explanation of why nasopharyngoscopy is necessary in this case.

An otolaryngologist performing a nasal endoscopy or nasopharyngoscopy may push the scope deeper into the throat to examine the larynx; similarly an otolaryngologist performing a diagnostic nasal endoscopy may use the same scope to examine the larynx. Code 31575 can be used in such cases but only if there is a medically necessary reason to evaluate the larynx endoscopically. If the otolaryngologist performs diagnostic nasopharyngoscopy and discovers a neoplasm in the patient's pharynx for example the larynx may also be explored for signs of malignancy.
 
Note: Some carriers do not include pharyngeal malignancy as a payable diagnosis for a flexible laryngoscopy (although a foreign body in the pharynx qualifies). It may be necessary to appeal such cases so that the medical necessity of the laryngoscopy can be explained.

Nasopharyngoscopy is bundled with both diagnostic nasal endoscopy and diagnostic flexible laryngoscopy. The Correct Coding Initiative indicates that 92511 should never be reported with 31231: The edit has a "0" indicator which means that it cannot be bypassed with modifier -59 (distinct procedural service) or any other modifier for any reason.
 
The edit that bundles 92511 with 31575 has a "1" indicator which means that 92511 can be reported during the same session as 31575. For example if the otolaryngologist examines the nasopharynx with a scope and evaluates the patient's larynx for a different problem later the same day 92511 could be reported separately (with modifier -59 appended). In such cases the documentation should leave no doubt as to why the second scope was required and the time of both procedures.
 
Coding E/M services performed at the same time as 92511 presents a potentially more difficult bundling issue. If the physician determines during the course of the service that the scope is necessary says Susan Callaway CPC CCS-P a coding and reimbursement specialist in North Augusta S.C. the E/M service and the scope should be paid separately with modifier -25 (significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended.
 
Callaway notes however that some carriers argue that 92511 is a simple diagnostic scope and that when it is used in conjunction with an E/M service the E/M is not significant or separately identifiable. "You have to make sure your documentation reflects the fact that the E/M led to the decision to perform the scope " says Callaway. "Even then if a private carrier is adamant that they won't pay for both because there only is one diagnosis there is little you can do."
 
For example the otolaryngologist performs nasopharyngoscopy on a new patient and initiates a treatment plan based on the findings. The otolaryngologist scopes the patient six months later and finds the problem has cleared up. Unless the otolaryngologist evaluates the patient for another reason no E/M should be billed as whatever was performed is considered to be included in the 92511 (minimal pre- intra- and postoperative evaluations are included in this service). Callaway recommends billing 92511 because it already includes the pre- intra- and post-procedure E/M services mentioned above. She also notes that 92511 pays at a higher rate than a low-level established patient visit code.