Otolaryngology Coding Alert

Question: We have a patient who came in with complaints of an earache. The provider noted a buildup of cerumen (nonimpacted) of the right ear and proceeded to remove it. The patient then noted that she had been experiencing a sore throat for the past few days. The provider performed a flexible laryngoscopy and found subtle swelling of the tonsils. What services can I bill out in addition to 99213?

Utah Subscriber

Answer: Since the cerumen is non-impacted, you should not consider using code 69210 (Removal impacted cerumen requiring instrumentation, unilateral). CPT^® guidelines instruct coders to refer back to the evaluation and management (E/M) code for visits that include removal of non-impacted cerumen.

However, the flexible laryngoscopy is a different story. You may bill out the flexible laryngoscopy separately using code 31575 (Laryngoscopy, flexible; diagnostic). Also, make sure to apply modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity…).

Note: Make sure the entry bullet in the E/M examination indicates the reason the laryngoscopy is necessary (i.e. “insufficient visualization and/or gag reflex). Additionally, the physician must also document a separate laryngoscopy procedure note.