Otolaryngology Coding Alert

Question: A patient came in for chronic ethmoid sinusitis that wasn't resolving. The otolaryngologist changed the patient's prescription. Because the patient also complained of hoarseness, the physician performed a scope and found the patient had a paralyzed vocal cord. Should I report the E/M service in addition to the scope?

Florida Subscriber

Answer: Absolutely, if the otolaryngologist's documentation supports both the service and the procedure. Ideally, he should write separate paragraphs for both with findings sections for each. The exam findings should indicate that the otolaryngologist was unable to visualize the larynx. He should include the larynx findings in the laryngoscopy section. This way he receives credit for the larynx findings once, not twice.

Although CPT does not require separate diagnoses to report an E/M service with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) in addition to a procedure, having two diagnoses helps show the insurer that the E/M service is significant and separate from the minor E/M included in the laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic). Make sure to link each diagnosis to the appropriate CPT code. To do so, follow these steps:

1. In box 21, enter 473.2 (Chronic sinusitis; ethmoidal) as diagnosis 1 and 478.31 (Paralysis of vocal cords or larynx; unilateral, partial) for diagnosis 2.

2. Complete box 24D and E as follows:

-- Answers to You Be the Coder and Reader Questions provided/ reviewed by Linda T. Ayers, MHCM, senior director of strategic alliances and health policy for the American Academy of Otolaryngology-Head and Neck Surgery; and 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.