Otolaryngology Coding Alert
Thorough Documentation Can Help Battle Endoscopy Denials
Question: Some of our physicians have been receiving denials for not documenting nasal endoscopies well enough. What should we be including in the notes?
Kansas Subscriber
Answer: Many practices (and some EMR systems) have to help the physicians complete a full report. Complete documentation of a fiberoptic and/or nasal endoscopy procedure with a distinct procedure report which should include:
Think of this procedure not as an office operative note that is included in the patient’s chart (paper or electronic).
Providers might also be asked to state within the physical exam or in the indication section the reason why the nasal endoscopy was medically necessary (i.e. indirect exam findings warranted further direct exam by scope due to inadequate visualization via manual exam, or gag reflex makes indirect exam impossible, etc.).
Many payers have internal edits in place to capture claims being submitted by physicians that may alert them to over billing. If something gets “flagged” in their system, the payer denies the claim for medical necessity and asks the practice to submit a reconsideration with medical notes. Your payer might be invoking a similar edit; it's an automatic way to basically request medical notes. Usually once the notes are submitted the claims get paid.
Don’t forget: Your notes are put under a microscope once you have to send them in on appeal in order to be paid what your physicians have earned. Make sure that all of your documentation can stand -up to full scrutiny.
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