Otolaryngology Coding Alert

Question: My physician performed a laryngoscopy, with operating microscope, excision of tumor, on a patient with a diagnosis of 478.4 (polyp of vocal cord of larynx). The patient smokes (two packs a day) and has chewed tobacco in the past. Therefore, the physician also felt it necessary to perform an esophagoscopy (43200, esophagoscopy, rigid or flexible; diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]). Medicare denied the 43200, and referred to a December 1997 bulletin that stated Medicare will not pay for screening procedures performed in the absence of signs or symptoms. A vocal cord polyp is not a covered diagnosis for an esophagoscopy, and when the carrier reviewed the office notes and dictation to determine whether the service was reasonable and necessary, it decided against the claim. Do you have any suggestions?

New Mexico Subscriber
 
Answer: Most Medicare carriers have issued a list of payable diagnoses for a variety of esophagoscopy and upper gastrointestinal endoscopic procedures. Unfortunately, if the diagnosis the otolaryngologist provided is not on the list, the carrier will not pay for the service, says Randa Blackwell, who codes for the department of otolaryngology at the University of Maryland in Baltimore.
 
Blackwell notes that unlike the bundling of bronchoscopy and laryngoscopy, which is an edit in the national Correct Coding Initiative (CCI), the esophagoscopy is denied on the basis of the diagnosis.
 
"The patient may well have had dysphagia (787.2), but if the otolaryngologist didn't document it, it can't be included," she says.
 
However, performing the esophagoscopy on a patient with a polyp on the vocal cord is considered good medical practice and may be the basis for an independent Fair Hearing appeal because laryngeal polyps sometimes do spread to the nearby bronchii or esophagus, notes Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist in Lakewood, N.J.
 
"You might lose the appeal, but what have you lost?" Cobuzzi notes. "You don't have to hire a lawyer, you just need to write a letter. And even if you lose, you'll learn to do a better job of using the dysphagia diagnosis, when appropriate, in the future."
 
Cobuzzi also suggests that a diagnosis of 989.84 (toxic effects of tobacco) could be used in the Fair Hearing to further justify the esophagoscopy, particularly because the patient chewed tobacco.
 
This diagnosis should not be confused with 305.1 (tobacco use disorder; tobacco dependence) or V15.82 (history of tobacco use), Cobuzzi notes. In particular, otolaryngologists who generally are not treating the patient's addiction to tobacco should not use 305.1 -- which is in the psychiatric section of the ICD-9 book. Rather, they are treating the physical effects of tobacco on tissue and other body parts, and this is appropriately reported using 989.84.