Otolaryngology Coding Alert

Know every detail your physician should be writing.

Otolaryngologists often perform diagnostic laryngoscopy in their offices, but you don’t simply report 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) and think your job is complete. You’ll also need to confirm that specific areas of examination are documented before the payer will process your claim.

Pay Attention to the Guidelines

Effective last year (Jan. 1, 2014), any payer requesting documentation for a scope procedure could either deny the service or reduce the physician’s payment if documentation doesn’t show that he examined all three areas during the laryngoscopy and noted the findings. CPT® guidelines state, “For endoscopic procedures, report appropriate endoscopy of each anatomic site examined. Laryngoscopy includes examination of the tongue base, larynx, and hypopharynx. If using operating microscope, telescope, or both, use the applicable code only once per operative session.”

Based on this guideline, your physician should examine the tongue base, larynx, and hypopharynx during a laryngoscopy. He also needs to clearly document each area’s examination and whatever findings he observed.

“Although it’s in writing now, the laryngoscopy has always included all these areas,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “That’s why I recommend using a form that has an anatomic picture on which the doctor can draw on to illustrate his findings to include within his procedure note. The doctor should always have a procedure note when they perform any of the endoscopies, including the layrongoscopy. By indicating his findings on the note, and using a drawing, it helps him show that all these area were examined.”

How it works: The physician can use check boxes on the form to show that he examined all three anatomic sites. He can also indicate any findings on the corresponding drawing of the mouth or larynx.

“If an area is found to be normal and this isn’t given as a choice on the form, he should indicate ‘normal,’ ‘wnl’ (for ‘within normal limits’) or a zero with a slash through it which means no remarkable findings on the procedure note to make sure an auditor will know he examined all areas,” Cobuzzi adds. “Leaving an area blank implies that it was not examined, not that there were normal findings. No one reading the procedure note can assume a finding is normal or otherwise when it is left blank.”

Watch the Details in Code Descriptors

As noted above, the base code for a diagnostic flexible laryngoscopy is 31575. Seeing terms such as “biopsy,” “removal of foreign body,” or “removal of lesion” in your physician’s notes will point you to other possible options:

• 31576 – Laryngoscopy, flexible fiberoptic; with biopsy
• 31577 – … with removal of foreign body
• 31578 – … with removal of lesion.

An otolaryngologist will only perform flexible laryngoscopies in the office, not rigid. This is because a flexible laryngoscopy enters through the nose and there is less of a resultant gag reflex than is found with a direct rigid laryngoscopy which enters directly through the mouth and usually requires sedation or general anesthesia. CPT® has separate codes for rigid direct laryngoscopy (31505-31571). The in-office procedures are done by nasal access and without any sedation.

When studying the code descriptors, being familiar with a few terms will help you understand the procedures represented.

• The term “direct” in the descriptor indicates the physician inserted the endoscope directly into the mouth.

• “Indirect” indicates he used a mirror to visualize things during the procedure, rather than an endoscope. The code for an indirect endoscope, 31505 (Laryngoscopy, indirect; diagnostic [separate procedure]), is actually just a mirror exam that does not involve an endocope. Since a mirror exam is included as part of the otolaryngology exam within an E/M service, there is rarely an instance when an indirect laryngoscopy is coded and billed.

• Procedures designated as “operative” are performed under general anesthesia or sedation.