Otolaryngology Coding Alert

As discussed in the previous article, otolaryngologists encounter a variety of diagnosis coding dilemmas when trying to prove medical necessity for a procedure. By billing signs and symptoms ICD-9 codes, otolaryngologists can increase medical decision-making for evaluation and management services, which will optimize reimbursement.

The following two examples show the subtle advantages of coding signs and symptoms.

782.8 (changes in skin texture)
A patient with an irritated spot on his ear that seems to be changing texture and now is scaly sees the otolaryngologist. The otolaryngologist decides to biopsy the area, and sends it to pathology. A few days later, the pathology report determines the problem is a seborrheic lesion.

The biopsy would then be coded 11100 (biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion). The confirmatory diagnosis, 702.11 (inflamed seborrheic keratosis), would be used for the biopsy; however, the appropriate E/M code would be billed with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service); 782.8 would be the corresponding diagnosis code for this visit.

By using this signs and symptoms code, the otolaryngologist indicates that the irritated skin patch was changing (which is why it was removed) and that it was not a cosmetic procedure. It also helps support the significant and separate nature of the -25 modifier attached to the E/M service billed.

786.09 (symptoms involving respiratory system and other chest symptoms, e.g., snoring)
A patient sees the otolaryngologist because his wife has been complaining about his heavy snoring, which could be caused by a nasal obstruction, such as turbinate hypertrophy, or obstructive sleep apnea. The otolaryngologist takes the patients history and as a result suspects the cause of the snoring is obstructive sleep apnea; without a sleep study, however, the otolaryngologist cannot be certain and should not use the apnea diagnosis, which labels the patient.

To rule out turbinate hypertrophy, the otolaryngologist examines the patient using a scope but the results are inconclusive and he or she orders a CT scan. Until that test and the sleep study are complete, the otolaryngologist cannot be certain which problem is causing the snoring, so 786.09 (symptoms involving respiratory system and other chest symptoms, e.g., snoring) would be the correct ICD-9 code to justify the visit.

The number of tests ordered and performed (scope, CT scan, sleep study) likely will boost the level of medical decision-making the otolaryngologist makes. In addition, the level of history also should increase due to the nature and number of questions the otolaryngologist likely asks, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J. The nature of the questions asked, Eisenberg adds, should allow a knowledgeable person to infer that sleep apnea is suspected even though, due to concerns about the patients privacy, the physician would not write this diagnosis in his or her notes.