Part B Insider (Multispecialty) Coding Alert

Your endoscopy coding needs an overhaul if you get these answers wrong

Get the lowdown on documentation requirements for an E/M or scope following sinus surgery with septoplasty so you don't bundle separately reportable items into the global period.

On Aug. 1, a physician performed a septoplasty (30520) with 90 global days, as well as bilateral total ethmoidectomies (31255) and maxillectomy with tissue removal (31267), which have zero global days. See if you can tell what to break out and what to include in the following Aug. 14 office note:

Height: 68 in.

Tobacco use: quit 10 years ago (PFSH -- social)

Allergies reviewed -- no changes (PFSH -- history)

Chief complaint: Patient returns to the office today in FU, status postnasal septoplasty, bilateral total ethmoidectomies and left maxillary sinusotomy with tissue removal.

History of present illness: Patient reports ongoing (HPI -- duration) "sinus headaches" (HPI -- associated signs and symptoms). She denies any purulent rhinorrhea (ROS -- ENT) or fevers (ROS -- constitutional). She does remind me that she has multiple types of head-aches, including migraines, etc. (HPI -- severity)

She indicates that she is irrigating 2-3 times per day (HPI -- modifying factors).

Physical examination: Anterior rhinoscopy reveals clear nose and midline septum (nose included in septoplasty's global package). Examined endoscopically patient's sinuses, including ethmoid sinuses bilaterally and left maxillary sinus (included in endoscopic exam). The patient's sinus surgery defects are healing nicely. There is no evidence of any infection, bleeding, etc. (findings included in endoscopy).

Impression: Satisfactory postoperative course.

Recommendations: Patient will continue to irrigate at least two times per day. We have asked her to return to see us on the three-month anniversary of surgery, some time in late September.

Procedure: Nasal/sinus endoscopy; bilateral ethmoid and left maxillary sinus endoscopy.

Anesthesia: Topical Lidocaine.

Findings: Included .

Procedure: Following adequate Lidocaine spray analgesia, inspected using the fiberoptic endoscope the patient's nasal cavities bilaterally, ethmoid cavities bilaterally and left maxillary sinus. Notes the above findings.

Patient tolerated the procedure well. No complications.

Question 1: Should the doctor report an E/M service?

The above office note has an expanded problem-focused history (HPI: 4 -- Extended; ROS: 2 -- Extended; PFSH: past, social 2 --Complete) but no physical examination or medical decision-making that stands separate from the scope's minor included E/M.

"I do not see enough documentation that would substantiate an E/M," says Michelle Logsdon, CPC, CCS-P, PCS, Falcon Practice Management in Toms River, N.J.

"More detail needs to be there to show me that the decision for the procedure was secondary to the actual visit," says Suzan Hvizdash, CPC, CPC-E/M, CPC-ED, medical auditor for the University of Pittsburgh Physicians.

Although the patient mentioned headaches, the physician made no further documentation to support an E/M and gave no treatment, says Ginny McManus, billing manager at BergerHenry ENT Specialty Group in New Jersey. It "looks like the patient returned to the office for a planned scope following sinus surgery." The E/M service does not represent an unrelated E/M service from the surgery that created the global period.

Exception: If the physician had treated and diagnosed the headaches and documented the medical necessity for the scope so that this portion stood alone (such as on a scope form), he could have gotten credit for the E/M service portion that is unrelated to the septoplasty's (30520, Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft) 90-day global period.

To indicate that the carved out non-nasal portion is unrelated to 30520's existing global period, you would need to append modifier 24 (Unrelated evaluation and management service by the same physician during postoperative period) to the office visit code (e.g., 99212-24).

Question 2: Should you code the scope as 31233?

You should use 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]).

You wouldn't bill 31233 (Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy) after postoperative maxillary sinus surgery because this code requires a puncture or trocar cannulation prior to placing the scope.

"The use of 31233 or 31235 to report diagnostic sinus endoscopy performed via an existing and patent opening into the maxillary or sphenoid sinus represents incorrect CPT coding," states the American Academy of Otolaryngology --Head and Neck Surgery in "Reporting Nasal/Sinus Endoscopy: CPT Codes 31233, 31235" (http://www.entnet.org/Practice/upload/31233-and-31235-endoscopy.pdf).

When a physician performs an endoscopic exam after a maxillectomy (31267) to view the interior of maxillary sinuses through existing surgically created patent sinusostomies, you should report only 31231, according to the Academy.