Otolaryngology Coding Alert

For major surgeries (those with 90-day global periods), the issue is fairly straightforward, says Randa Blackwell, coding specialist with the department of otolaryn-gology at the University of Maryland in Baltimore. "If the otolaryngologist sees a patient and, as a result of that visit, surgery is performed that day or the next, the visit may be reported separately with modifier -57 appended," she says.

Although many of the procedures with 90-day global periods performed by otolaryngologists are prescheduled, or elective, this is not always the case, Blackwell notes. For example, the otolaryngologist may admit a patient with parotitis to the hospital. Three days later, the patient develops a parotid abscess that requires draining. At that time, the otolaryngologist makes a decision for surgery (to drain the abscess) and indicates it by appending modifier -57 to the hospital care code, which is reported in addition to the surgery.

"This lets the carrier's computer know that although the hospital visit being reported is part of the procedure's global period, it may be billed separately because the decision for the surgery was made during that encounter," Blackwell says, adding that this applies to visits performed the day before surgery with a 90-day global period as well.

"That's why it's very important to append modifier -57 to the E/M service. Otherwise, the carrier has no way of knowing that the surgery was not preplanned but, rather, resulted from the examination," she points out. "This is particularly important for inpatient consultations, which result in next-day surgery. But even though this initial examination determined the need for the surgery, it must be appended with modifier -57, or it won't get paid."

For example, the otolaryngologist may evaluate an adult patient who has been intubated for two days. The otolaryngologist determines that a tracheostomy is required because the patient cannot tolerate the intubation much longer. In such cases, modifier -57 must be appended to the appropriate-level E/M code reported with 31600 (Tracheostomy, planned [separate procedure]), which has a 90-day surgical package.

For minor procedures, coding is more complicated. Depending on the circumstances, E/M services may be separately reported. Most carriers require that modifier -25 be appended to the E/M code billed with a same-day procedure (if the E/M service represented a separate, significant service).

Like modifier -57, which requires only that the visit resulted in a decision for (major) surgery, modifier -25 may be used appropriately if the E/M visit revealed the need to perform a procedure or other service. However, it also may be appended if the patient has a different problem (i.e., separate diagnosis), Blackwell notes.

"The visit is separately identifiable if it resulted in the decision to perform the procedure or if it is in relation to a different problem," she says. A second diagnosis always is helpful, when appropriate, although Medicare and CPT do not require it, she adds.

Patients often arrive with a sign or symptom that becomes a definitive diagnosis after a history is taken and an examination performed. In such cases, the sign or symptom should be linked to the E/M code, whereas the procedure code should be linked to the diagnosis.

For example, the patient complains of an earache (388.70). The otolaryngologist performs a history and physical (H&P) and decides to perform nasopharyn-goscopy (92511), which reveals a pharyngeal mass (784.2) that is causing the ear pain. The E/M visit should be associated with the earache diagnosis (388.70, Otalgia, unspecified; earache NOS), whereas the nasopharyngoscopy should be linked to 784.2 (Swelling, mass, or lump in head and neck).

The second, often-overlooked criterion for modifier -25 is that the E/M visit be significant, Blackwell adds. If the otolaryngologist performs a procedure and also assesses the patient for an unrelated but minor problem, it may not be appropriate to report the E/M separately, she says.

Scenario 1: The otolaryngologist performs a tympanostomy on a patient with otitis media. During the course of the preoperative evaluation, the otolaryngologist finds that the patient has a history of asthma, which is being managed by her primary care physician.

"In this case, even though there is a second diagnosis, a separate E/M service should not be billed because the E/M services provided for that condition were not significant," Blackwell says.

Scenario 2: The otolaryngologist performs videostro-boscopy on a patient with hoarseness to check for polyps or neoplasms. The findings of the preoperative examination reveal esophageal reflux.

In this case, the otolaryngologist may be able to report a low-level established patient visit, Blackwell says. However, only the E/M services related to the reflux should be counted when determining the level of the visit. The portion of E/M related to the stroboscopy is included in that procedure and should not be taken into account to boost the level of the visit. The correct diagnosis for the E/M service would be gastroesophageal reflux (530.81). A diagnosis of hoarseness (784.49) should be used with the videostroboscopy.

Although virtually any procedure with a zero- or 10-day global period may be performed with an E/M service, the procedures listed below consistently generate coding, documentation and payment questions.

Mirror exam during office visit: CPT includes a separate code (31505, Laryngoscopy, indirect; diagnostic [separate procedure]) for mirror examinations of the larynx. In most cases, the otolaryngologist uses the mirror as an element of the otolaryngologic examination.

"I think that the only time an indirect laryngoscopy should be reported is when it is the only service performed," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "If you consistently report the mirror exam and the E/M service separately with modifier -25, you are sending up a very large red flag for an auditor."

Removal of ear wax: This service, which is reported using 69210 (Removal impacted cerumen [separate procedure], one or both ears), may be reported separately, but only if both services are well documented and the patient's chart indicates that the exam was significant and separately identifiable. In theory, otolaryngologists should be able to obtain payment for both services, which are not bundled in the Correct Coding Initiative (CCI).

Cobuzzi notes that many Medicare and private payers state that cerumen removal is incidental to an E/M service, arguing that a complete otolaryngologic examination cannot be performed if the patient's ear is full of wax. To improve the chance of payment, separate diagnoses, whenever appropriate, should be used for the cerumen removal and the E/M service, she says.

"You need modifier -25 because minor procedures (those with zero and 10 global days) are considered by the AMA [American Medical Association] to have a minor E/M built into them. So, if someone has an appointment to come in for an ear cleaning, the small evaluation you do of the person before cleaning their ears is part of 69210 and is not billable," she says. "However, if the patient has another complaint that requires history, examination and medical decision-making (MDM), the exam should be reported separately because the second diagnosis proves the earwax removal is being performed for an entirely different reason."

For example, she says, if the patient has a sore throat and during the examination the otolaryngologist finds and removes impacted cerumen, the claim has a greater chance of being paid.

Cobuzzi stresses that the diagnoses must be different. "You can't use ear pain or hearing loss for the E/M and impacted cerumen for the wax removal. You need an entirely different diagnosis, like laryngitis or sinusitis."

Even in such cases, carriers still may deny the E/M claim, and appealing the decision may not help. "Many payers will never pay for removing impacted cerumen with E/M services, no matter how hard you fight and how good an argument you present," Cobuzzi says. Medicare carriers probably will pay, she adds, if the documentation is clear and accurate.

Control of epistaxis: The otolaryngologist sees a patient with a severe nosebleed. The patient's history is obtained, and an otolaryngologic examination is performed. The otolaryngologist decides to control the epistaxis endoscopically (31238, Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage).

Because the visit resulted in the decision to control the bleeding endoscopically, some carriers may pay separately for the appropriate E/M code that is reported with modifier -25 appended. Others may deny the claim because epistaxis cases are emergent and the E/M services provided are perfunctory and incidental to the procedure.

To obtain payment, the otolaryngologist should document briefly the thought process that led to the decision for endoscopic control of epistaxis. For example, the procedure note could say that because the bleeding was so severe the scope was required to locate the bleed and place electrocautery, laser or chemical cautery instruments parallel to the scope to stanch the bleeding.

Note: In this case, modifier -25 is supported even though only one diagnosis (784.7, Epistaxis) is appropriately linked to the E/M and the scope.

If, however, the patient has a nosebleed and the otolaryngologist makes a quick assessment, packs the nose and sends the patient home, only the epistaxis control code (most likely 30901*, Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method) should be reported.

Diagnostic procedure returns negative: A patient may arrive with a sign or symptom that prompts the otolaryngologist to perform a diagnostic procedure. If the procedure does not yield a positive diagnosis, the sign or symptom that prompted the test must be associated with the E/M that led to the decision to perform the test, and with the diagnostic procedure. For example, the patient visits the otolaryngologist complaining of hoarseness (784.49) and a diagnostic flexible laryngoscopy (31575) is performed. The E/M service and 31575 are linked to 784.49 because the laryngoscopy did not yield a definitive diagnosis.

When payment is denied in these circumstances, otolaryngologists should appeal, making sure to stress the reason for the procedure, not the result. The appeal should let the carrier know that the same diagnosis code was used in a rule-out situation (and physicians are instructed never to report procedures associated with rule-out diagnoses).

Claims involving modifier -25 and modifier -57 should be documented clearly and accurately. This means making sure that:

"Unless the documentation indicates that a significant, separately identifiable E/M service was provided and that means documenting, in most cases, a history, examination and MDM modifier -25 should not be used," Cobuzzi emphasizes.

"Billing a claim incorrectly (i.e., adding modifier -25 just to get paid) is fraudulent," she adds. "Modifier -25 claims, in particular, should be scrutinized carefully before being reported because carriers tend to watch them so closely."