Otolaryngology Coding Alert

Question: Insurers keep bundling 9921x-25 into 31575, even when I use separate diagnoses. I send in the documentation, but the evaluator doesn't think the otolaryngologist's chart notes support a separate E/M. He includes one paragraph for the service and procedure and one for his impressions. Do you have any advice?

Michigan Subscriber

Answer: Encourage your otolaryngologist to write separate impression and plan notes for 9921x-25 (Office or other outpatient visit for the evaluation and management of an established patient -; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 31575 (Laryngoscopy, flexible fiberoptic; diagnostic).

Rolling the E/M and procedure descriptions and impressions into one paragraph each makes it difficult for the representative to see that the otolaryngologist had to perform the E/M to do the procedure.

Remember: A minor procedure's global package includes a small, related E/M. To separately report a service, documentation must show a history, examination and medical decision-making that is more than the minor E/M associated with the minor procedure.

Watch out: The E/M can't include any findings from the laryngoscopy. You can include findings from the manual viewing of the larynx in the E/M's examination portion to indicate the need for the laryngoscopy. But the findings from the laryngoscopy count toward the procedure. You can't count the larynx findings from the laryngoscopy under both the E/M exam and the laryngoscopy procedure note.

Here's documentation showing that a standalone E/M service led to the decision to perform laryngoscopy:

E/M: I performed a comprehensive head and neck examination. General appearance is normal. The patient is in no distress. She is hoarse, but I note no stridor. External canals and tympanic membranes are clear. Intranasal exam shows deviated septum to the right but no intranasal masses or polyps. Oral exam is negative. Oropharynx is clear.

Neck exam shows previous surgical scar and no other palpable masses, adenopathy or thyromegaly.

Impression: Associated hoarseness and dysphagia (933.1, Foreign body in pharynx and larynx; larynx) with intermittent aspiration, cause yet to be determined. The vocal cord on the right is fairly well medialized, and I don't think she has much to gain by medialization thyroplasty.

She may eventually require repeat collagen injections, but I would favor this over thyroplasty because I think that with her previous surgery and subsequent scar tissue in the area, thyroplasty would not be straightforward.

Plan: I need to do flexible laryngoscopy to evaluate vocal cords.

Procedure: Fiber optic exam of nasopharynx, hypopharynx is negative. Fiberoptic laryngoscopy shows right true vocal cord paralysis, but the right true cord is in fairly good midline position and the left approximates it well on phonation. No obvious aspiration noted today.

Impression: The patient has true vocal cord paralysis (478.32, Paralysis of vocal cords or larynx; unilateral, complete).

Plan: I recommend the patient receive repeat collagen injections.

-- Answers and/or information for You Be the Coder and Reader Questions reviewed/provided by Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.