Otolaryngology Coding Alert

Question: An established patient with a history of nasopharyngeal cancer was seen in the office for a laryngoscopy. The physician also documented an E/M and removed impacted cerumen from both ears. The patient completed chemo and radiation therapy about a year ago and the physician has the patient come in every 6 months now for cancer surveillance. Since the patient doesn’t have any symptoms other than a dry throat, and no evidence of disease, I’m having a hard time figuring out what diagnosis code to use for 31575. Both Z codes I’ve considered (Z85.818 and Z08) fall into an LCD edit as not meeting medical necessity. Should I bill just the E/M and 69210 and forgo billing 31575 since I have no other diagnosis that can be billed with 31575?

Indiana Subscriber

Answer: As long as the notes are in order, you should be able to report 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) rather than an E/M code with 69210 (Removal impacted cerumen requiring instrumentation, unilateral).

Remember there’s a distinction between “no evidence of disease” and “history of cancer.” A patient may still carry the cancer diagnosis but have no evidence of disease. Because of this, you shouldn’t include a history code unless the physician has specified that the patient is cancer free and in remission. Even so, the cancer diagnosis alone should not be necessary to meet medical necessity for the procedure.

If the provider documents no evidence of disease and there is no further treatment directed to the cancer, then you should consider it a history of cancer. Do not report a code for the neoplasm even if it “gets the service paid.” If the patient is still undergoing treatment (such as taking Tamoxifen for breast cancer), it is correct to code active breast cancer because of the treatment. The patient in your scenario has no evidence of disease and is not having further treatment, so it is not appropriate to code this as active cancer.

Because your physician has not documented that the cancer is in remission, the most appropriate diagnoses are Z85.818 (Personal history of malignant neoplasm of other sites of lip, oral cavity, and pharynx) and Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm). Because these diagnoses are not in the local coverage decision for 31575, you will most likely need to appeal a denial that you receive for the claim. The doctor will need to make a case for continued cancer surveillance based on American Cancer Association guidelines.