Otolaryngology Coding Alert

A new patient comes into your practice with complaints of recurrent sinusitis, headache, and some fever and pressure through the sinus area. The otolaryngologist takes the patients history and performs a physical exam. Perhaps an x-ray or another kind of diagnostic test is performed. It is clear from the test results that the sinuses are opaque. The physician discusses the situation with the patient, and a decision is made to perform an endoscopic debridement (31237, nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]).

In this encounter, it would be appropriate for the otolaryngologist to bill both for the visit using the appropriate new patient E/M code (99201-99205, office or other outpatient services) and the procedure (31237), according to Emily Hill, PA-C, a member of the American Medical Associations (AMA) Relative Value Update Committee, Correct Coding Policy Committee and CPT-5 Project, and the managing partner of Hill & Associates, a consulting firm specializing in coding, compliance and reimbursement, in Wilmington, NC.

However, to correctly bill for both, Hill says, you must provide separate documentation. She even recommends including a procedure note with the documentation for the E/M, so that when the record is reviewed, it is clear that two distinct services (the E/M and the debridement) were rendered. The E/M visit would also be appended with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Without the modifier, the E/M would be bundled into the procedure, and not be reimbursed separately.

In the example above, the same diagnosis codeeither 461.0-461.9 (acute sinusitis: maxillary, frontal, ethmoidal, sphenoidal, other, unspecified or 473.0-473.9 (chronic sinusitis)would be used both for the exam and the debridement.

Note: In CPT 1999 there is a clarification that says a physician may use modifier
-25 to bill a visit and use the same diagnosis that was used for the procedure.

E/M Usually not Billed When Procedure is Pre-scheduled

Perhaps the otolaryngologist decided initially to treat the same patient with antibiotics and instructed the patient to return in 10 days for a debridement if the symptoms havent improved.

If the patient returns and the sinuses havent improved, the physician may decide to perform the debridement then and there. Depending on the amount of history taken and examination performed, another E/M visit, albeit at a lower level, may possibly be billable, though this is unlikely. In this example, the evaluation may be so small that only the procedure is billed. Similarly, if the procedure was pre-scheduled, there is no justification for billing for another E/M service even if the doctor examines the patient right before surgery, Hill explains.

This also applies to patients with a history of chronic sinusitis who periodically require endoscopic debridement. These patients may know themselves when they require debridement, and may actually schedule appointments on their own for the procedure. Again, a minimal E/M service is performed that could not be categorized as separately identifiable or significant.

Notes: 1. Hill also points out that even if a biopsy or polypectomy is performed, no added reimbursement should be expected, because both are considered part of procedure code 31237. 2. If the debridement was performed bilaterally, modifier -50 (bilateral procedure) should be attached to 31237.