Outpatient Facility Coding Alert

Question: We received a denial for code 92511 for due to an incorrect diagnosis code. The diagnosis codes we reported are H69.91, J30.89, and Q67.4. The patient’s chart also documents nasal congestion. Should I resubmit the claim with a nasal congestion diagnosis or appeal with the current diagnoses?

Indiana Subscriber

Answer: You can check a CPT^® code and ICD-10-CM code’s compatibility two different ways. First, you can check your Medicare Administrative Contractor’s (MAC’s) Local Coverage Determinations (LCDs) for code 92511 (Nasopharyngoscopy with endoscope (separate procedure)). Another option is to check the ICD-10-CM coding crosswalk for 92511. Using the crosswalk, you will not find a match for any of the following three diagnoses:

• H69.91 — Unspecified Eustachian tube disorder, right ear
• J30.89 — Other allergic rhinitis
• Q67.4 — Other congenital deformities of skull, face and jaw.

While none of these diagnoses are a match, you will find that R09.81 (Nasal congestion) is a positive match in the coding crosswalk. Assuming it also matches up in your LCDs, you should expect to submit 92511 with R09.81 and receive payment. However, your documentation must support it.

In the instance that you do not have a code that links in the crosswalk, your next option would be to appeal the claim. This would require that you fully explain to the insurance carrier why each of the respective diagnosis codes justify payment for an endoscopic nasopharyngoscopy. This might be most easily performed using the example of H69.91 by explaining the anatomical connection between the nasopharynx and the eustachian tubes.  

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