Otolaryngology Coding Alert

"Mutually exclusive" means the otolaryngologist wouldn't perform these procedure together. "Our surgeons don't usually bill laryngoscopic lesion removal codes together," agrees Mary Hameister, reimbursement manager at Pediatric Ear, Nose & Throat of Atlanta.

An otolaryngologist may use a flexible scope to check the vocal cords prior to putting in a direct scope to finish the procedure in a different operative session. "But at an excision session, the surgeon usually just inserts the chosen scope and removes the lesion," Hameister says.

If an otolaryngologist does perform multiple lesion removals at the same session, you should bill only the most extensive procedures. "You can only get reimbursement for one treatment of a lesion at a time," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

In addition, you shouldn't report 31545 plus 31546 due to mutually exclusive procedure rules. The otolaryngologist  uses either local tissue flaps (31545) or grafts (31546) for reconstruction following vocal cord tumor removal.

Surgical Procedure Includes Diagnostic Scope

Another laryngoscopy coding tenet that you should commit to memory is that an operative scope includes the diagnostic scope. NCCI applies this guideline to make two diagnostic laryngoscopy codes (31525, Laryngoscopy, direct, with or without tracheoscopy; diagnostic, except newborn; and 31526, ... diagnostic, with operating microscope) components of 31545-31546. "I don't think anyone will have a beef with these edits," says Randa Blackwell, coding specialist at The 33rd Street Surgery Center in Baltimore. 

Most otolaryngologists realize that an insurer will not pay for two scopes at the same time. "If the surgeon puts in a scope to look at the area and then performs an operative procedure, the most extensive procedure always includes the diagnostic scope," Blackwell says.

Exception: When the surgeon performs the scopes as two separate events, you should report both the diagnostic and the operative scope. NCCI allows a modifier to override the edits for 31525-31526 with 31545-31546.

For instance, an injured patient comes to the hospital. An otolaryngologist performs a direct diagnostic scope due to the patient's respiratory problems and discovers he has a vocal cord tumor.

Later the same day, the patient has increased stridor and laryngeal edema. The otolaryngologist decides to remove the tumor and use a graft to reconstruct the area.

Coding: You should report both the diagnostic and the operative scope. "The otolaryngologist performs the scopes at different sessions," Blackwell says. Thus, modifier 59 (Distinct procedural service) breaks the usual diagnostic-laryngoscopic reconstruction bundle. Assign 31546 for the laryngoscopy with excision and graft and 31525-59 for the lesser-valued diagnostic laryngoscopy.

Important: Check the NCCI edits to see if you can report bronchoscopy in addition to laryngoscopy. For instance, you may bill diagnostic bronchoscopy, 31622 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]), with some laryngoscopy codes. But the edits prohibit reporting some operative bronchoscopy codes, such as 31628-31631

Complex Laryngoscopy Includes Lesser Scopes
 
You should also always report the most extensive laryngoscopy procedure. For this reason, the edits bundle laryngoscopy codes 31535 (Laryngoscopy, direct, operative, with biopsy), 31536 (... with operating microscope) and 31576 (Laryngoscopy, flexible fiberoptic; with biopsy) with 31545-31546. If an otolaryngologist uses a scope to perform multiple procedures, the most extensive procedure includes the lesser procedures.

How it works: An otolaryngologist does a direct scope with biopsy and then uses the same scope to do an excision followed by flap reconstruction. In this case, insurers will pay the surgeon "for placing the scopes once," Blackwell says. "The direct scope with biopsy (31535) is inclusive to the direct scope with excision and flap (31545)."

Once again, NCCI permits you to unbundle these edits, when appropriate. Suppose in the above example that the otolaryngologist instead performed the scope with biopsy in the emergency department and then later performed the excision and reconstruction. "NCCI allows payment for both scopes because the surgeon performs them at separate times," Blackwell says. Use modifier 59 on the lesser procedure - the scope with biopsy (31535-59) - in addition to 31545 for the scope with excision and flap.

3 Scopes, Exam Are Part of 31545-31546
 
A host of new edits will unfortunately always be unreportable. You won't be able to use a modifier to override edits that bundle four ENT codes with 31545-31546. Component codes include: