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Otolaryngology Coding Alert

READER QUESTION:

Panendoscopies for Cancer

Published on Fri Nov 01, 2002

Question: How should we code for triple endoscopies to receive reimbursement for all procedures laryngoscopy, direct (31535); esophagoscopy (43200); and bronchoscopy (31622)? We see patients with laryngeal carcinoma and feel that all procedures are necessary for diagnosis and treatment. I have tried using modifier -59 with no success. For the Medicare Ohio carrier, Palmetto GBA, I reported 31535, 31622-59-51 and 43200-59. The evaluation of benefits lists the reason for denial as:

  • 31535 charges exceed our fee schedule or maximum allowable amount

  • 31622-59-51 charges exceed our fee schedule or maximum allowable amount; charges are reduced based on multiple-procedures rules

  • 43200-59 these are noncovered services because this is not deemed a "medical necessity" by the payer.

    Ohio Subscriber

    Answer: Although panendoscopies or triple endoscopies generally are standard medical practice in certain situations, such as with cancer patients, the national Correct Coding Initiative (CCI) bundles surgical laryngoscopy code 31535 to diagnostic bronchoscopy code 31622. The edits contain an indicator of "1," however, meaning you may report both procedures if they are distinct and separately identifiable and you append modifier -59 to the lesser-valued procedure. CCI does not bundle esophagoscopy code 43200 to either procedure, which means it is usually payable separately.

    "If the operative report indicates three different scopesadministered and removed at three individual times, report the procedures separately," says Cheryl Odquist, CPC, American Academy of Professional Coders (AAPC) San Diego local chapter president and president of Codeology in San Diego.

    For the laryngoscopy, assign 31535 (Laryngoscopy, direct, operative, with biopsy). For the bronchoscopy, report 31622 (Bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]).

    For the esophagoscopy, use 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Append 31622 and 43200 with modifier -59. Link the bronchoscopy and the esophagoscopy to V71.1 (Observation for suspected malignant neoplasm). A separate diagnosis for the laryngoscopy, such as 161.9 (Malignant neoplasm of larynx; larynx, unspecified), will help substantiate your claim and prove medical necessity.

    However, if the otolaryngologist inserted one scope only and explored surrounding areas, only the endoscopy is reimbursable. If the operative report simply states that the physician administered the approach with the endoscope and observed each segment larynx, esophagus and bronchi for the possibility of a secondary neoplasm (V71.1), the payer will reimburse for 43200 only.

    Your case is unusual because the carrier denied the esophagoscopy (43200). Look at the carrier's local medical review policies to see if the diagnosis you listed is acceptable. If the carrier does not cover panendo-scopies for cancer patients, have your otolaryngologist explain why the procedures are necessary.

    Note: Some payers may not follow CCI edits, so ask your carriers for their policy on billing laryngoscopy and bronchoscopy.

    Clinical and coding information for You Be the Coder and Reader Questions provided and reviewed by Cheryl Odquist, CPC, American Academy of Professional Coders (AAPC) San Diego local chapter president and president of Codeology in San Diego; and Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.

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