Otolaryngology Coding Alert

Question: The otolaryngologist recently performed an esophagoscopy with removal on a child who had a foreign body in the esophagus. Because he did not believe that the amount of foreign body removed from the esophagus could sufficiently explain the child's symptoms, he then performed a bronchoscopy, which returned negative. At that point, the otolaryngologist endoscopically examined the child's nasopharynx through the nose and found the remainder of the foreign body. How should I code this?

Montana Subscriber

 
Answer: Proper coding is difficult to establish without an operative note, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's editorial panel and executive committee.  

There are two issues here. First, because the bronchoscopy returned negative, a specific ICD-9 code must be used to justify the service. The op note should include a "Findings" stating:
 

Why the otolaryngologist felt it necessary to perform the three scopes
 

What the otolaryngologist found using the scopes.

 
Second, there is no obvious code for the endoscopic removal of a foreign body from the nasopharynx.
 
The esophagoscopy should be reported using 43215 (esophagoscopy, rigid or flexible; with removal of foreign body). The correct ICD-9 code in this case is 935.1 (foreign body in esophagus).
 
The bronchoscopy is coded 31622 (bronchoscopy, rigid or flexible; diagnostic, with or without cell washing [separate procedure]). The "negative" bronchoscopy requires a situation-specific ICD-9 code. Because the bronchoscopy returned negative, adds Eisenberg, a short explanation listing both findings and the reasons for the three scopes is particularly important.
 
There is no shortage of codes to describe the removal of the foreign body from the nasopharynx. Among the best candidates are the following:
 

30310 -- removal, foreign body, intranasal; requiring general anesthesia; 3.93 RVUs
 

42809 -- removal of foreign body from pharynx; 3.42 RVUs
 

92511-22 -- nasopharyngoscopy with endoscope [separate procedure]; unusual procedural service; 1.30 RVUs without modifier -22 addition.

 
In this case, the correct code is also the highest valued. Although 42809 describes the removal of a foreign body from the pharynx -- which clinically is differentiated somewhat from the nasopharynx -- it describes what was performed to a higher level of specificity than the other codes, particularly if the otolaryngologist moved the foreign body down from the nasopharynx into the pharynx and then removed it (as is often the case).
 
The language of ICD-9 code 933.0 (foreign body in pharynx or nasopharynx), which would be appropriately linked to the nasopharyngeal procedure performed, indicates both pharynx or nasopharynx, further strengthening the case for 42809 as the correct code.
 
Although 30310 describes removal of a foreign body in the nose, it is less specific than 42809. The same can be said for the nasopharyngeal endoscopy under general anesthetic (92511), which does not mention the removal of the foreign body. If this code were used, modifier -22 (unusual procedural services) would be required to indicate to the carrier that this was more than a diagnostic endoscopy of the nasopharynx.
 
The insurer will require a detailed operative report before making payment for this unusual service. Additionally, when payment is received, the explanation of benefits (EOB) should be carefully reviewed to make sure all the services charged were in fact reimbursed.