Otolaryngology Coding Alert

Question: In central New York, a major carrier has implemented a 20 percent coinsurance on all surgical procedures performed in the office. This has directly affected payment for our 31231 procedures. Although the procedure is diagnostic, it is listed in the surgical section of the CPT manual. Can the use of 92511 reduce or eliminate the above-mentioned problems because it is considered a medicine code and not a surgical one?

New York Subscriber

Answer: Generally, in a 92511 (nasopharyngoscopy with endoscope [separate procedure]) the physician is looking down the back of the throat (the nasopharynx area). During a 31231 (nasal endoscopy, diagnostic), the physician is looking in the sinuses. In other words, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator based in North Augusta, S.C., the two codes are not identical and should not be substituted. In particular, 92511 should be used only for specific purposes, such as examining adenoidal size or identifying lesions in the nasopharynx. If the physician is doing something else, coders shouldnt bill this code, Callaway-Stradley says, noting that it isnt appropriate to change codes simply to get paid.

A good rule for coders to follow is to use whichever code best describes what the documentation supports. Our sources reveal that an increased number of audit requests involving 92511 and 31231 by Medicare and private payers have been reported.