Otolaryngology Coding Alert

Tip: Look to the AAO-HNS for some helpful guidance.

Diagnostic scopes can be some of the most common procedures an otolaryngologist performs, but do you have solid knowledge of when it’s correct to report an E/M code and modifier 25 with the scope? 

“The proper use of modifier 25 continually becomes of increasing importance as the definitions and bundling changes with minor procedures and E/M services,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. 

Our experts share insights on when you can – or 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)to legitimately boost your reimbursement.

Start With the Basics of Global Days 

Every procedure on the Medicare Physician Fee Schedule is assigned a global period of 000, 010, 090, XXX, YYY, ZZZ, or MMM. Each designation shows how many days are associated with the service represented by that procedure code: 

• 000 – Zero days (minor surgical procedure)

• 010 – 10 days (minor surgical procedure)

• 090 – 90 days (major surgical procedure)

• YYY – The individual carrier sets the procedure’s global period.

• ZZZ – The procedure is associated with another procedure; this related procedure determines the global period for the ZZZ code.

• MMM – Maternity procedures. 

The global period concept does not apply to procedures classified with XXX.  

Scopes are considered a minor surgical procedure and have a designation of 000 global days. In general, E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure, according to the current CCI manual for coding Medicare services. As the guidelines state, “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.”

Caveat: However, the guidelines continue by stating that a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure can be separately reportable with modifier 25. You just need to have clear documentation of such. 

Assess Whether Modifier 25 Applies 

Remember all surgical procedure codes have an inherent E/M component. Ask yourself: What has my provider done to go “above and beyond” a minimal E/M service that’s included in the procedure code? Does his or her documentation support that additional work and effort? 

Example 1: An established patient returns for follow-up of hoarseness after two weeks of voice rest. Her mirror exam is now within normal limits. However, she complains of green nasal drainage so the physician performs a nasal endoscopy and diagnoses her with acute maxillary sinusitis. You would submit 9921x-25 for the E/M service along with 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) for the diagnostic endoscopy. 

Example 2: Established patient returns for follow-up of hoarseness after two weeks of voice rest. The physician performs a flexible fiberoptic laryngoscopy and ascertains that the results are within normal limits. In this situation, you have a choice between two codes – 9921x E/M or 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). You cannot report both codes because the physician’s work wasn’t enough to merit the E/M code with modifier 25. 

“The -25 modifier doesn’t need to be appended to every E/M service just because something else was done during the visit,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, Director of PB Central Coding for Allegheny Health Network in Pittsburgh, PA. “The guidelines and instructions illustrate that only when a procedure with a minor global period is performed on the same day as a separately identifiable visit does the modifier have to be appended. I think practices trip over this because they’re afraid the other service will interfere with the payment of the E/M service.”

If a patient presents for a planned procedure, only code for the procedure unless the patient’s condition warrants a separate E/M. Examining the area where the procedure is performed does not support a separately identifiable E/M. 

Example 3: A patient is scheduled for a post-operative debridement after FESS surgery. The endoscopic debridement is scheduled and planned. Even though a small E/M is documented and performed, it is not really a separate and significant identifiable E/M service. As such, even though there may be a fully documented E/M service and fully separately documented endoscopic debridement (31237, Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]), the E/M cannot support the 25 modifier and only the 31237 should be coded and billed.

Follow AAO-HNS Guidelines for Success

Use the AAO-HNS clinical indicators as a guideline to support when you file a claim for a procedure on the same day as an E/M service. If your provider’s documentation addresses all the elements in the clinical indicator, the payer should allow reimbursement for both services. 

Clinical indicators for laryngoscopy/nasopharyngoscopy include: 

• History 

• Exam (an inadequate complete ENT exam (including a mirror exam) and a description of the patient’s breathing and voice) 

• Tests 

• Post-exam observations 

• Outcome review (including documentation of the procedure, findings, and any complications on the day of the procedure). 

The same clinical indicators apply for nasal endoscopy, with a more extensive exam: 

• History 

• Exam (anterior rhinoscopy insufficient to account for the patient’s symptoms; abnormal anterior rhinoscopy requiring more thorough nasal evaluation including [but not limited to] suspected chronic rhinosinusitis, sinonasal polyposis, neoplasm, and/or foreign body) 

• Tests 

• Post-exam observations 

• Outcome review. 

Final note: “It is important to keep in mind that you should not be coding and billing an E/M service every time you perform a diagnostic scope,” Cobuzzi says. “To add further reasons why E/M services and minor procedures should not be billed together, CCI bundled all established E/M services with all minor procedures in July of 2014. So, not only are we prohibited from billing the two together unless we can support the separate and significant nature of the E/M service by the definition of a minor procedure’s global period, but CCI added a bundle as well.”