Otolaryngology Coding Alert

Hint: Get all your documentation straight first.

Although your otolaryngologist knows what to expect from many patient visits, surprises sometimes arise – and complicate your coding. Such is the case with office visits that include scopes. If more of your payers seem to be denying these claims, read on for your refresher on points to keep in mind.

Point 1: Know What the Visit Includes

Chapter verbiage in CCI specifically states that you cannot use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) as the “decision to perform a minor procedure.”

“However, that is what we are experiencing,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J. “It is a daily CPT® pairing that is seen in the otolaryngology office.”

Example: The physician plans to complete an E/M service but finds that manual inspection of the nose and/or larynx and/or nasopharynx is not sufficient to give her the information she needs. She decides to perform a diagnostic endoscopy. The test is not included in the E/M service and the diagnostic service was not planned (the patient was not scheduled to have a diagnostic endoscopy).

The minor global period associated with diagnostic endoscopies includes a small E/M service. Even though modifier 25 is not supposed to be used as a decision for surgery, the physician’s note must reflect that she provided a greater service than the small E/M associated with the scope and that the intent of the patient’s visit was not the performance of the diagnostic scope.

“Documentation also needs to show that the scope was not planned and a decision to perform it was made based on the manual exam of the specific anatomy that applies,” Cobuzzi says. “That helps justify appending modifier 25 to the E/M code.”

Point 2: Have Extra Documentation With Planned Scopes

If you’re reporting a planned scope, you need to demonstrate that the E/M was more than the small clearance needed to be done in order to perform a scheduled scope.

Plus: In 2013, CCI added more complications and hoops for doctors to jump through in order to support an established E/M and a minor procedure, when they bundled all minor procedures with established patient E/M services (codes 99211-99215), creating a “double wall” against billing scopes and minor procedures.

“So, if the scope is planned and there is medical necessity to do more than the ‘pre op’ E/M before doing the scope, the E/M note must demonstrate the medical necessity for doing more of an E/M,” Cobuzzi explains. “This usually means that the E/M is being performed for very separate diagnoses and problems unrelated to the scheduled scope.”

For example, a patient comes for a one-year follow up to a neoplasm which was removed from the posterior nasopharynx wall. The doctor scheduled a diagnostic laryngoscopy during this follow-up. While capturing the interval history as part of the small E/M that is part of the minor procedure, the patient complained of ear pain and perceived hearing loss in his left ear. The doctor then extended his E/M to address the ear complaints reflected in the

History of Present Illness (HPI) documented specific to the ear. As a result, the doctor billed an E/M with a 25 modifier for the ear complaints and the laryngoscopy for the history of cancer. A battery of audiology testing was also ordered in order to evaluate the ear problems. This would be coded: 99213-25 with diagnoses H93.292 (Other abnormal auditory perceptions, left ear) and H61.892 (Other specified disorders of left external ear) 31575 with diagnoses Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm) and Z85.29 (Personal history of malignant neoplasm of other respiratory and intrathoracic organs).

Any audiology testing would be coded and submitted separately, under the audiologist’s NPI for Medicare and any private payers who require the audiologist to submit under their own NPI. The audiology testing would be submitted under the doctor’s NPI for any private payers that do not credential audiologists.

Point 3: Watch Your Wording

If you appeal a denial for an unplanned scope with an E/M visit, remind your provider to not simply use the words “decision to perform” in her documentation. Instead, include a thorough explanation of the situation.

Example: Good explanatory documentation might be, “the scope was not planned and the patient was just scheduled for an E/M. Upon performing the E/M, the physician determined that she needed additional information and decided to add the scope during the visit. If you, as the payer do not feel you can pay for these two distinct services when they are efficiently documented, during the same visit, we may have to consider scheduling the patient for follow up visits for their needed scopes. The patients will be told that they are not getting their full work up at their visits because their payer refuses to pay for every service that is required to diagnose and treat them.”