Otolaryngology Coding Alert

Question: Our patients are examined after FESS with a nasal endoscope, and may not need debridement. I know that FESS (functional endoscopic sinus surgery) does not include a global period. Is it correct to report an E/M service and a diagnostic endoscopy for the service? 

New Mexico Subscriber

Answer: Yes, you may report the nasal endoscope separately as 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]). Documentation must clearly mention that the physician performed a detailed examination using a nasal endoscope.  

Be sure that the E/M service is separately identifiable from the scope procedure, and that you don’t include the endoscopy finding in the exam section of the E/M service. Keep in mind that not only does the minor procedure, 31231 have a small E/M service included in its value, but established E/M services were bundled into minor procedures as of July of 2013.  You have to make sure you can support the significant and separate nature of the E/M service from the diagnostic endoscope if you are going to append modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or service) to the applicable E/M code from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …).