Outpatient Facility Coding Alert
Know the Diagnosis Codes That Support 31575
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Question: Which diagnosis codes support 31575?
Ohio Subscriber
Answer: Medical policies differ regarding diagnoses that support performing 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). But some indications for 31575 may be:
You may use the ICD-9 code associated with the indication for the E/M service (such as 99201-99215, Office or other outpatient visit...) and, when available, link the definitive diagnosis to the scope (31575) to help show medical necessity.
Example: An established patient presents complaining of hoarseness (784.42). The physician performs and documents a history, exam, and medical decision-making. Based on his findings, he decides a laryngoscopy is necessary and separately documents the procedure. The scope reveals a polyp (478.4, Polyp of vocal cord or larynx). Because the physician performed a separate history, exam, and medical decision-making from that included in the laryngoscopy, the visit meets modifier 25’s definition (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).
Therefore, you should report 9921x-25 (Office or other outpatient visit for evaluation and management of an established patient ...) in addition to 31575. Link the E/M to 784.42, and link the scope to 478.4. You don’t technically need a separate diagnosis to bill 9921x-25. But two ICD-9 codes help substantiate the E/M’s significant and separate nature.
Error averted: The physician should not include any of his laryngoscopy findings in the exam. He should choose a reasonable E/M level in which none of the larynx exam’s content goes into the E/M’s exam. There should be no double counting. Each exam must stand on its own. However, if the physician documents the failed attempt to exam the larynx and surrounding structures in the exam and also documents the decision to perform the flexible scope, you could count the bullets for the failed attempts in the exam -- separate from the laryngoscopy note.
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Know the Diagnosis Codes That Support 31575
Question: Which diagnosis codes support 31575? Ohio Subscriber Answer: Medical policies differ regarding diagnoses that support performing [...]