Otolaryngology Coding Alert

Anatomy paints picture of 92511, 31231 or 31575 territory

You can net almost $100 more in diagnostic scope pay if you can spot the words that should keep you with 31231 or 92511 instead of 31575.

With ENTs billing Part B carriers for 537,507 scopes with 31575 in 2006, you can't afford to miss capturing higher-paying codes when the physician performed and documented the medically necessary service. An otolaryngologist can actually make more money per hour on in-office procedures than in surgery, says Bob Glazer, CEO of ENT and Allergy Associates in Tarrytown, N.Y., based on a study he conducted. The office setting is much less bureaucratic and thus allows for a more efficient patient flow than a hospital.

The numbers should be on your side if you grasp these scope fundamentals.

Dispel 92511 -Loser- Myth

"ENT coders often don't want to code 92511 because they think it pays the least of the flexible scope codes," says 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. The code's total value, however, is in between the lower-paying 31575 and the higher-paying 31231.

Using the 2008 Medicare Physician Fee Schedule and first-half conversion factor of 38.0870, the codes- relative value units and payments in ascending order include:

Surprise: Although 92511 pays $41.90 more than 31575, and 31231 pays $64.37 more than the laryngoscopy code, the Correct Coding Initiative considers 31575 the comprehensive code. CMS forgot to change the bundles when it revalued the codes, Cobuzzi says. Code 31575 includes 92511 and 31231.

Check for 31575 Medical Necessity

Trace how far a flexible scope goes to see if you-re in 31231, 92511 or 31575 territory. Use 31231 for a scope of the nasal cavity. Code 92511 reflects viewing up until the nasopharynx. Code 31575 is for a medically necessary scope that examines all the way down to the larynx.

Example: An ENT used topical lidocaine for anesthesia and performed flexible fiberoptic laryngoscopy via the right nostril. The procedure note indicates, "The nasopharynx, vallecula, epiglottis, sinuses and vocal cords were all visualized."

Because the scope goes all the way into the larynx, 31575 might be correct based on anatomy. You should use 31575 instead of 92511 only if the note shows that examining this far was medically necessary. "There has to be a chief complaint and a history of a laryngeal problem," Cobuzzi says.

"If, however, the ENT examines only the nasopharynx, such as for eustachian tube dysfunction or a mass in the nasopharynx, you would code 92511," Cobuzzi says. For information on billing a separate E/M, see "Crack Down on Flexible Laryngoscopy Coding Mishaps With These FAQs" in the March 2007 Otolaryngology Coding Alert.

Spot -Rigid- or -Flexible-

To choose between 31525 (Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn) and 31575 (Laryngoscopy, flexible fiberoptic; diagnostic), look at the type of scope and location. "Code 31525 is for rigid laryngoscope, and 31575 is for flexible laryngoscope," says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich.

Clinical lowdown: Physicians may use a rigid scope, which is a straight metal instrument that goes through the mouth into the throat, for surgical procedures, such as removing foreign objects, collecting tissue (biopsy), removing polyps, or performing laser surgery, Merrill says. A rigid scope also aids in diagnosing cancer of the voice box (larynx). Physicians perform the procedure in the operating room under sedation.

In contrast, a flexible scope allows better diagnostic views, is tolerated better by patients and can be performed in the office. "It is a pencil-thin, flexible fiber optic scope that goes in through the nose and then down the throat," Merrill says.

Example: An otolaryngologist documents a "direct laryngoscopy used to view the vocal cords by using a fiberoptic scope without taking a biopsy." In this case, you should code the procedure with 31575. Link the diagnostic code to the chief complaint, such as halitosis (784.99, Choking, sneezing, halitosis, mouth breathing).

Replace 31575 for Abnormal Findings

When your otolaryngologist finds a problem during a diagnostic scope, you should convert from the diagnostic scope code to a surgical flexible scope code The surgical scope code includes the diagnostic scope, according to CPT guidelines and multiple endoscopy payment rules.

Suppose during the above fiberoptic scope scenario the ENT found and biopsied a polyp on the vocal cords (478.4, Polyp of vocal cord or larynx). You should assign 31576 (- with biopsy), rather than 31575 for a diagnostic laryngeal scope.

Other procedures the ENT might perform with a flexible laryngoscope include removal of the following:

- foreign body (31577) with 933.1 (Foreign body)

- lesion (31578) linked to 478.29 (Pharyngeal polyp).

Similarly, if during a nasal scope for obstruction, the ENT found and removed a polyp , you would report 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) instead of the diagnostic nasal scope (31231).