Otolaryngology Coding Alert

When an otolaryngologist performs an evaluation and management service and a flexible laryngoscopy on a patient on the same day, the chances of getting reimbursement rise dramatically if the decision-making portion of the E/M supports the medical necessity of using the scope.

Increasingly, carriers are including flexible laryngoscopy 31575 (laryngoscopy, flex-ible fiberoptic; diagnostic), also known as nasopharyngeal laryngoscopy (NPL) as part of the E/M services otolaryngologists provide to their patients. It is no coincidence that growing numbers of otolaryngologists have been performing NPLs on their patients during the course of a routine examination in place of indirect laryngoscopy 31505 (laryn-goscopy, indirect [separate procedure]; diagnostic), commonly referred to as the mirror.

In a policy statement aimed presumably both at insurance carriers and their own membership, the American Academy of Otolaryngology-Head and Neck Surgery has stated that flexible laryngoscopy should NOT be considered a routine part of the initial visit by a patient. In other words, it is not simply a high-tech replacement for a mirror.

The procedure, which can be performed in the otolaryngologists office, involves inserting a flexible fiberoptic laryngoscope through the nose or mouth to examine the interior of the larynx and offers unique information in the functional and anatomic assessment of the upper airway, according to the AAO-HNS policy statement.

Unlike indirect laryngoscopy, which is included in any E/M service code , the NPL is not a bundled procedure. It also should not be confused with 31515 (laryngoscopy direct, with or without tracheoscopy; for aspiration), which is a hospital-based procedure. It is also worth noting that a nasal endoscopy can turn into a flexible laryngoscopy if the otolaryngologist decides he or she wants to view deeper down the patients throat.

You would convert a 31231 (nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) or a 31237 (nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) to a 31575, for example, when examining a patient who has sinus problems but also has indication for gastro-esophageal reflux disease (GERD), says Barbara J. Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a coding and reimbursement firm in Lakewood, NJ.

Note: CPT codes 31231 and 31237 also may convert to 31576 (laryngoscopy, flexible; with biopsy) or 31578 (with removal of lesion).
 

E/M Documentation Should
Provide Medical Necessity

According to Cobuzzi, otolaryngologists are unwittingly helping carriers reject bills for flexible laryngoscopy performed at the same time as E/M services because they are documenting the NPL within the examination portion of the E/M service, bolstering the carriers claim that the laryngoscopy was part of the exam.

The solution, Cobuzzi says, is to keep the documentation of the E/M separate from that of the laryngoscopy. Otolaryngologists need to document taking the patients history, performing the examination and their medical decision-making on the basis of the visual examination. They need to ensure the E/M service stands on its own, without the NPLs findings.

If the E/M documentation shows that the otolaryngologist made the medical decision to perform a flexible laryngoscopy based on the patients history and exam, the claim is far more likely to be paid, Cobuzzi says. The laryngoscopys findings should be listed separately from the E/M documentation, like a mini-operative report. A second diagnosis, if borne out by the scope, also should be listed.

Cobuzzi stresses that the procedure should only be performed when it is deemed necessary. Its a more invasive procedure, she says, adding that using it for a routine examination is like getting an x-ray for a cough. First, the physician would use a stethoscope.

On the other hand, if the otolaryngologist has performed a thorough exam and decided he needs the scope to take a better look, he can bill for both using a -25 modifier (significant, separately identifiable evaluation and management service on the same day as the procedure or other service), says Stella Almassian, administrator of the Otolaryngology Department at Northwestern University in Chicago, IL. But Almassian says the procedure must be substantiated by serious documentation, or there is little chance it will be paid.

The only time we can ethically bill out 31575 and a -25 for an exam is when a brand-new patient comes in
with various symptoms or complaints. In those circumstances, you really have to do a very good detailed history and exam to determine if this patient needs a procedure or not, Almassian says, adding that If the flexible scope simply replaces the old-fashioned mirror, they cant justify billing for it.

Increasing numbers of otolaryngologists use the scope regardless of reimbursement problems. Flexible scopes are expensive but they have replaced the laryngeal mirror, Almassian says, because the otolaryngologist gets a really good look at the upper airway.

The scope helps the physician examine patients with strong gag reflexes. They also can assess vocal cord mob-ility, see the ventral surface of the epiglottis, the lateral pharyngeal walls, eustachian tube orifices and pyriform sinuses, says Gretchen Segado, assistant compliance manager at Thomas Jefferson University in Philadelphia, PA.

Segado and Randa Blackwell, a coding specialist with the Department of Otolaryngology at the University of Maryland in Baltimore, developed a checklist of 10 indications for use of the scope (see box).

If the otolaryngologist is performing a complete evaluation, its important to understand all the areas that can be examined by the scope, because some just cant be assessed by the mirror, Segado says.

Note: Some indications listed above may not provide medical necessity for all carriers. For instance, circumventing gag reflex may be considered merely patient or physician convenience.

Since many otolaryngologists continue to favor the scope over the mirror for routine exams, practices also need to decide on when it is more appropriate to bill for the E/M or the scope. Almassian recommends billing for the scope rather than the E/M service only when there is sufficient documentation. If the otolaryngologist scopes the patient and finds nothing, E/M should be billed; if the scope reveals something, that should be billed in place of the E/M.