Otolaryngology Coding Alert

Question: When an otolaryngologist performs fiberoptic nasal sinus endoscopy and fiberoptic laryngoscopy on the same date of service, should Medicare deny or bundle the codes? My billing staff informed me that as of July 2003, our carrier will no longer accept modifier -51 but will accept only modifier -59 for reimbursement of these claims. Medicare denied payment and said that if we sent supportive medical records the insurer would reconsider its decision. Did Medicare publish a new ruling regarding these codes?

Texas Subscriber

Answer: Through the National Correct Coding Initiative version 9.2, effective July 1, 2003, Medicare bundled nasal sinus endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) with flexible fiberoptic laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic). To override the edit, you will have to use modifier -59 (Distinct procedural service) rather than modifier -51 (Multiple procedures).
 
Before you submit 31575, 31231-59 claims, make sure that documentation supports billing the endoscopy as a distinct procedural service. Medicare wants to see that your otolaryngologist performs endoscopy and laryngoscopy for different reasons.
 
For instance, if an otolaryngologist performs endoscopy (31231) and laryngoscopy (31575) to evaluate difficulty swallowing (787.2, Dysphagia), you shouldn't report the endoscopy. The otolaryngologist employs both scopes for the same reason. So Medicare will bundle 31231 into 31575.
 
On the other hand, separate complaints will make it easier to receive payment for 31231-59 in addition to 31575. Suppose an otolaryngologist performs nasal endoscopy to evaluate purulent nasal drainage (478.1, Other diseases of upper respiratory tract; other diseases of nasal cavity and sinuses). Because the patient complains of frequent sore throats (462, Acute pharyngitis), the ENT also performs laryngoscopy to rule out malignancy (149.0, Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx; pharynx, unspecified) and gastroesophageal reflux disease (530.81; Other specified disorders of esophagus; esophageal reflux). In this case, you should assign 31575 and 31231-59.
 
Because the otolaryngologist performs endoscopy to evaluate the nasal passages, and laryngoscopy to examine vocal fold mobility and laryngeal function, you should code the scopes as separate procedures. Make sure to link any findings or symptoms to the related procedure.
 
For denials in which documentation supports billing 31231 as a distinct procedural service, you should resubmit the claims with modifier -59 appended to 31231. With the correspondence, include a copy of the chart notes, which should ideally contain separate procedural notes for 31231 and 31575. Also, include a letter explaining why the patient's medical condition required performing two separate scopes.