Revenue Cycle Insider

Don’t forget to justify separate and significant E/Ms.

You see notes documenting cerumen removal, epistaxis, and laryngoscopies almost every day of the week. But are you sure you’re coding them correctly?

In her Regional HEALTHCON 2024 presentation “ENT Procedure and Surgery Coding: The Basics and the Mindblowers,” Dottie Davis, CPC, COC, CGSG,CEMC, CPMA, physician team lead coder for medKoder in Mandeville, Louisiana, offered a timely refresher on basic coding principles surrounding all three of these common procedures. And she provided sage advice on how to justify billing for an additional evaluation and management (E/M) service when appropriate.

Take a look at her suggestions and see if you need to change some of your familiar coding habits.

Take Care to Code Cerumen Removal Correctly

You probably already know that two CPT^® codes — 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) and 69210 (Removal impacted cerumen requiring instrumentation, unilateral) — describe a provider’s removal of cerumen impacted in a patient’s ear. Yet both codes are still subjects of confusion among otolaryngology coders.

First, Davis noted that adding modifier 50 (Bilateral procedure) is no longer applicable for these unilateral codes. Instead, you may need to use laterality modifiers RT (Right side) and LT (Left side) as appropriate and depending on payer preference.

Additionally, as their descriptors note, both codes require use of instrumentation; any service in which a provider removes nonimpacted cerumen would be documented with a low-level office/outpatient evaluation and management (E/M) service such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … straightforward medical decision making ...). However, Davis noted the E/M can be billed with a cerumen removal code using 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), providing the additionally is justified, such as the patient being treated for an unrelated condition like sinusitis.

Take Control of Your Epistaxis Coding

Again, like cerumen removal, the process of controlling a nosebleed can be coded with a low-level E/M if the provider simply stops the bleeding and does not perform the services listed in the CPT^® codes. Also, like cerumen removal, the epistaxis codes — 30901(Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method), 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method), 30905 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial), and 30906 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent) — are unilateral. But with these codes, you will add need to modifier 50 for bilateral treatment, according to Davis.

Davis also noted that you can use another CPT^® code — 31238 (Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage) — but this describes a surgical procedure in which a patient is anesthetized, and the provider uses an endoscope to treat the nasal bleeding.

Be Flexible in Assigning Laryngoscopy Codes

Davis pointed out the importance of knowing the difference between the indirect and direct diagnostic laryngoscopy codes. Code 31505 (Laryngoscopy, indirect; diagnostic (separate procedure)), the most common indirect laryngoscopy code, describes a procedure where the provider uses a laryngeal mirror to view the patient’s larynx, while the direct laryngoscopy code, 31525 (Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn), describes a laryngoscopy performed with a laryngoscope.

However, providers can perform direct diagnostic laryngoscopies with rigid or flexible laryngoscopes, with flexible laryngoscopes being the most common. You’ll use 31525 to document rigid laryngoscopies, but 31575 (Laryngoscopy, flexible; diagnostic) for flexible direct diagnostic laryngoscopies.

Davis noted that it is possible to code for both a laryngoscopy and a separate office/outpatient E/M service for a given encounter. One such situation would be where the provider cannot look down the patient’s throat due to the patient having a condition such as stenosis or a narrow airway. In such situations, you would document the reason for the laryngoscopy and bill the laryngoscopy code along with the appropriate E/M code with modifier 25 appended to show the provider performed a significant and separate E/M.

A second laryngoscopy and E/M-25 scenario would occur when the provider showed the patient’s plan of care changed after performing the laryngoscopy. In other words, “if they thought they were going to treat the patient one way, then based on the findings of the laryngoscopy, they decided on a second course of treatment,” that would justify billing a separate and significant E/M in addition to the laryngoscopy, according to Davis. In such a situation, Davis explained, “I would tell the provider to put in their note, ‘The following treatment plan was made based on the findings of the laryngoscopy.’”

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC