Otolaryngology Coding Alert
Documentation Is Key With Failed Mirror Exam
Question: May I report a comprehensive otolaryngology exam if I perform a mirror examination of the nasopharynx, but visualization is less than optimal secondary either to a hyperactive gag reflex or difficult patient anatomy? Answer: Yes, you may claim a comprehensive examination with an unsuccessful mirror exam. Make sure you carefully document the attempt and why you could not complete it.
If no other compelling reason exists to perform a nasal endoscopy to examine the nasopharynx, does an attempted examination fulfill the requirements for a comprehensive otolaryngology examination?
Mississippi Subscriber
The documentation should explicitly state that you attempted a mirror exam but could not perform the procedure either due to your inability to see adequately or because of the patient's gagging.
Be careful: Medical necessity must exist to perform the nasal endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]). Many carriers are limiting ICD-9 codes that support nasal endoscopy. A diagnosis such as sinusitis (for example 473.x, Chronic sinusitis), should support the procedure. Check your carrier's Web site for applicable local medical review policies.
Otolaryngology Coding Alert
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