Otolaryngology Coding Alert

Including diagnostic laryngoscopies and nasopharyngoscopy with esophagoscopy procedures follows accepted coding principles. Thus, the edits shouldn't shock most coding experts. "None of these changes will affect the daily billing in our office," says Shawn Langston, CPC, coder for Mitchell D. Kaye, MD, FACS, in Hopkinsville, Ky.

Don't Bill Diagnostic Laryngoscopy With Esophagoscopy

These edits follow correct coding guidelines, which allow you to bill for the most extensive scope used, if the component scope does not result in a surgical procedure. "Similar to gastrointestinal coding for colonoscopies, if a physician uses a scope and pushes it in, stops and evaluates the area, and then pushes the scope further in, you may only bill for the farthest area that the scope reaches," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.

Of course, with otolaryngology, the ENT uses multiple scopes. He usually inserts one scope, the laryngoscope (for instance 31575), pulls it out and puts in the second scope, an esophagoscope (such as 43200, diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), Cobuzzi says. Because the esophagoscopy (43200) includes the diagnostic laryngoscopy (31575), you may report only the most extensive scope performed: the esophagoscopy (43200).

Similarly, if a surgeon looks at a patient's nasal passages and pharynx using a flexible fiberoptic endoscope (92511) and also uses an esophagoscope to view the patient's esophagus (43200-43232), you should not separately report the nasopharyngoscopy (92511), Cobuzzi adds.

Some otolaryngologists, however, separately bill for the diagnostic laryngoscopy or nasopharyngoscopy when they perform esophagoscopy only, says James N. Palmer, MD, assistant professor in the division of rhinology in the department of otorhinolaryngology, head and neck surgery at the University of Pennsylvania in Philadelphia. "If a surgeon uses an esophagoscope and looks at the patient's larynx on the way down, that's not sufficient reason to bill the diagnostic laryngoscopy," he says.

The edits contain an indicator of "0." Therefore, NCCI does not permit using a modifier, such as modifier -59 (Distinct procedural service), to unbundle the laryngoscopy or the nasopharyngoscopy during the same procedural encounter.

31575-31579 Include Looking at the Sinuses

NCCI also targets flexible fiberoptic and rigid laryngoscopy codes (31575-31579), which now include sinus endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]). Luckily, these edits should not financially impact your ENT's practice. "We never billed both procedures anyway," Palmer says.

Other coding experts concur with Palmer. "We already follow the guideline that the endoscopy is bundled into the laryngoscopy," says Rhonda Buckholtz, CPC, practice manager at Crawford and Fitch Ear, Nose and Throat in Franklin, Pa. Therefore, she does not feel that the NCCI edit will affect her practice's daily billing or bottom line.

The bundle makes sense, as long as the scopes are for the same diagnosis, says Michael J. Hammer, MA, L/CCC-SLP, associate director in the laryngeal laboratory department of otolaryngology head and neck surgery at the University of Kansas School of Medicine in Kansas City. For instance, an otolaryngologist performs endoscopy (31231) and laryngoscopy (31575) to evaluate difficulty swallowing (787.2, Dysphagia). In this case, because the physician performs the scopes for the same reason, 787.2, the laryngoscopy includes the endoscopy.

Some otolaryngologists would bill separately for the procedures even when they did not use both scopes. "By definition, when an otolaryngologist performs a flexible fiberoptic laryngoscope, he looks at the pharynx and larynx," Palmer says. But, if the physician uses a flex scope with a nasal approach, the scope passes through the sinuses. Therefore, some otolaryngologists would bill for the diagnostic nasal endoscopy for looking at the sinuses on the way down, he says. The edits now indicate you should not separately report the endoscopy (31231).

2 Diagnoses Support 31579, 31231-59

Some surgeons may disagree with the laryngoscopy/sinus-endoscopy bundle based on the argument that the scopes, particularly rigid laryngoscopes and endoscopes, examine different anatomic areas for separate reasons. Although a flexible fiberoptic laryngoscope allows the otolaryngologist to view the nasal passages, a rigid laryngoscope does not, Palmer says. "Rigid laryngoscopes permit better viewing of the vocal cords, whereas sinus endoscopes offer clearer visualization of the sinuses," he says.

NCCI accommodates this concern by allowing a modifier to override the edits in certain circumstances. "If a surgeon clearly documents separate diagnoses that support performing 31231 and 31575-31579, you should report both procedures with modifier -59 (Distinct procedural service) appended to 31231 to indicate a separate site," Palmer says.

For instance, a patient has chronic sinusitis (473.9, Unspecified chronic sinusitis) and a laryngeal polyp (478.4, Polyp of vocal cord or larynx). The surgeon uses a rigid laryngoscope to obtain better video scopes (31579, Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy) and a nasal endoscope (31231) to more clearly view the patient's sinuses. In this case, you should report both procedures (31579, 31231-59) and link the laryngoscopy to 478.4 and the endoscopy to 473.9, Palmer says.

Because the physician performs endoscopy to evaluate the sinuses and the laryngoscopy to examine vocal fold mobility and laryngeal function, you should code the endoscopy and the laryngoscopy as separate procedures, Hammer says. "They represent unique examinations with a unique purpose and unique sets of findings, clinical skills and separate documentation."