Otolaryngology Coding Alert

Question: When we perform an office visit or a consultation that results in 92511 or 31575, should we use modifier -25 or -57?

Illinois Subscriber

Answer: Although coders usually append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to E/M services performed with minor procedures and reserve modifier -57 (Decision for surgery) for services provided with major surgeries, some variations occur based on payer. For instance, Medicare limits modifier -57 to E/Ms involving major surgeries, procedures that contain 90-day global periods.

But some third-party payers require modifier -57 on E/Ms provided with minor surgeries, services that have zero- or 10-day global periods, such as 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). Although this is not the right way to code according to CPT, individual insurer policies supersede accepted coding practice. Therefore, if a payer requires modifier -57 with minor surgical codes, get the policy in writing to protect yourself in case of an audit.

Regardless of insurer, on visits involving nasopharyn-goscopy (92511, Nasopharyngoscopy with endoscope [separate procedure]), you should not report an E/M appended with modifier -57. Because 92511 is a medicine code, not a surgical code, using a "decision for surgery" modifier is inappropriate. Consequently, for E/Ms with 92511, you should use only modifier -25 if documentation supports the visit.

Before using modifier -25 on the E/M code, make sure the visit is separately reportable. Because the National Correct Coding Initiative includes a minor E/M with codes that contain zero global days, like 31575 and 92511, you should only report an E/M that qualifies as a significant, separately identifiable service from the scope. To show that the office visit (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient) or consultation (99241-99245, Office consultation for a new or established patient) led to the procedure, you should encourage your otolaryngologist to dictate the procedure separately from the E/M documentation. Thus, the payer can easily see that the physician provided a history, examination and medical decision-making, which led to the decision to perform 31575 or 92511.