Otolaryngology Coding Alert

Choosing the correct code can make a difference of $28.

When you're attempting to distinguish nasopharyngoscopy from laryngoscopy, just remember this: What matters most is the area the ENT examines, not where he inserts the scope.

Site Examined Determines Proper Code

When choosing between nasopharyngoscopy (92511, Nasopharyngoscopy with endoscope [separate procedure]) and laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic), you should consider not whether the ENT introduces the scope through the mouth or the nose, as you might think. Instead, the key to proper coding is the anatomic area (nasopharynx or larynx) the ENT examines with the scope. As such, the medical necessity is also dictated by the area that the physician needs to view based on the patient's complaints and history of present illness.

How mistakes happen: Sometimes physicians choose to perform a nasal scope insertion for a laryngoscopy because inserting the scope through the patient's nose is easier than making the patient hold his mouth open for a long time, and because going through the nose doesn't provoke the patient's gag reflex. So if you read "nasal scope insertion" in your physician's documentation and assume he performed a nasopharyngoscopy, you could be jumping to an incorrect conclusion.

Money matters: Remember that 92511 reimburses higher than 31575 in the nonfacility setting (4.25 total relative value units vs. 3.44 total RVUs, or about a $28 difference, on average), so choosing the correct code has significant meaning for your bottom line.

Additionally, payers may deny what is coded based on the medical necessity supported (or not supported) by the diagnoses. This could affect whether you will receive your entire reimbursement. For example, if a physician performs a nasopharyngoscopy to view the eustachian tubes in the nasopharynx with a diagnosis of eustachian tube dysfunction (381.81), the scope would be supported. But, if the physician codes a nasopharyngoscopy for laryngitis with obstruction (464.01), a payer may or may not feel that 92511 is supported and as such, it may be more work for you to get paid.

Solution: Read your ENT's documentation very thoroughly to discern what anatomic part he examined with the scope procedure -- this fact should guide your code selection.

For example, if the documentation states the physician performed a nasal scope insertion and examined the interior of the patient's larynx (this provides a better view of the upper airway than a traditional mirror exam), you would report 31575.

If, however, the physician examines the nasopharynx (that is, the eustachian tubes, adenoids and choanae, or the area where the pharynx and the nasal passages meet at the end of the hard palate), the correct code is 92511, regardless of where the ENT introduces the scope.

Call on 25 for Same-Day Scope and E/M

After you determine the correct scope code to report, you need to know whether you can bill for a same-day E/M service if your ENT performs one. You can't always bill for an E/M on the same day as 92511 or 31575. To code for both services, you must have documentation that supports the medical necessity and the separate and distinct nature of the two services.

You must also append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code you report.

Example: Otolaryngologists often make a same-day decision to perform a laryngoscopy. A patient may present for a completely separate problem (or for the same problem if the scope was not previously scheduled and the results of the E/M lead to the scope), and after the ENT provides the E/M service he may decide that a laryngoscopy is needed.

In this case, you can bill for both the E/M (with modifier 25) and 31575 as long as the physician's documentation clearly explains the distinct reason for the laryngoscopy. And, the physician should provide a separate procedure note for the laryngoscopy so you have documentation that both services are separate and distinct.

Don't include the findings from your laryngoscopy in the larynx portion of the patient's exam. This would be double counting, getting credit for the scope procedure and for the exam bullet. You can count only one. Ideally, the larynx bullet in the exam should demonstrate the medical necessity and decision for the scope, and your physician documents the findings from the scope on the separate procedure note.

Don't do this: You cannot bill for both the E/M and 31575 if the patient comes in specifically for a laryngoscopy and the physician only takes the patient's vital stats but doesn't perform a full and separate E/M.