Otolaryngology Coding Alert

Question: I have received numerous denials of medical necessity on fiberoptic laryngoscopy (31575) for globus because the code, apparently, is not on local coverage determination (LCD). How can I reverse this policy to our favor?

New Jersey Subscriber

Answer: You can try for an appeal. You will probably lose at redetermination level (the first level) because carriers just look at the LCD, but you might win at the next level, reconsideration. Medicare carriers have to use a panel of physicians when it is a medical necessity issue. You want to make your case by providing literature and clinical references and reasons why it is medically necessary to perform the scope for globus, (784.99, Other symptoms involving head and neck), a feeling of a lump in the throat.

The physician has to visualize the larynx and surrounding sturctures to check if there is anything creating that sensation in the patient and the only way to get adequate visualization is usually a flexible laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic). The physician must document the medical necessity for performing the scope, with an indication that he "does not have adequate visualization on manual inspection with a mirror", or the "patient has a gag reflex on mirror exam", etc. Make sure you do not use the ICD-9 code for globus hystericus (300.11, Conversion disorder), which is a psychiatric diagnosis, and not related to the complaint your throat patient is coming to your otolaryngology practice for diagnosis.

Outline: Section 1869 of the Social Security Act defines LCD as "a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A)." LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) of the Act.

Drawback: When you win, it is just for that claim. You cannot rest on your laurels and assume that the problem has been fixed for future claims. Appeal wins are just for each claim and date of service and have no long reaching implications.

Fix the LCD permanently: You still have to go to the carrier's medical director or the carrier advisory committee to get the LCD permanently changed for future claims, so that you do not have to appeal every time your physician performs a laryngoscopy for this diagnosis. You can use your success from your reconsideration as part of the information you bring to your carrier medical director or carrier advisory committee to convince them to modify the LCD for the long haul. This option is not a losing battle, most carriers are willing to listen to a compelling argument for medical necessity that justifies adding the missing diagnosis(es).