Part B Insider (Multispecialty) Coding Alert

Tip: Make this 'rigid' versus 'flexible' scope distinction.

Are you relying on 31575 for all your diagnostic scope claims? You could be denying your practice up to $80 per claim, and during these times, you can't afford to miss a dime. If you can spot these key terms for 31231 or 92511, then you can boost your claim's bottom line.

The numbers should be on your side if you grasp these scope fundamentals.

Dispel 92511 'Loser' Myth

If you're like many ear, nose, and throat (ENT) coders, you may not want to code 92511 (Nasopharyngoscopy with endoscope [separate procedure]) because you "think it pays the least of the flexible scope codes," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPCP, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. Actually, the code's total value is in between the lower-paying 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) and the higher-paying 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]).

Using the current Medicare Physician Fee Schedule's conversion factor of 34.0376, the codes' relative value units and payments in ascending order include:

Surprise: Although 92511 pays $27.57 more than 31575, and 31231 pays $79.99 more than the laryngoscopy code, the Correct Coding Initiative considers 31575 the comprehensive code. Code 31575 includes 92511 and 31231.

Check for 31575 Medical Necessity

Trace how far a flexible scope goes to see if you're in 31231, 92511 or 31575 territory. Use 31231 for a scope of the nasal cavity and sinuses. Code 92511 reflects viewing the nasal cavity down the throat until the nasopharynx (the edge of the soft palate). Code 31575 is for a medically necessary scope that examines all the way down to the larynx.

Example: An ENT used topical lidocaine for anesthesia and performed flexible fiberoptic laryngoscopy via the right nostril. The procedure note indicates, "The nasopharynx, vallecula, epiglottis, sinuses and vocal cords were all visualized."

Because the scope goes all the way into the larynx, 31575 might be correct based on anatomy. You should use 31575 instead of 92511 only if the note shows that examining this far was medically necessary. "There has to be a chief complaint and a history of a l problem requiring viewing all the way down to the larynx" Cobuzzi says.

"If, however, the ENT is only looking for the condition of the nasopharynx, such as for eustachian tube dysfunction (the eustachian tube terminate in the nasopharynx) or a mass in the nasopharynx, you would code 92511," Cobuzzi says.

Should You Make This 'Rigid' or 'Flexible' Distinction?

Although you may think 31525 is for rigid laryngoscope and 31575 is for flexible laryngoscope ��" end of story ��" you need to remember that the nasal exam (31231) may involve a rigid scope. Therefore, you cannot assume a rigid scope is a laryngoscopy done under sedation.

Hint: ENTs do not perform rigid laryngoscopies in the office. Providers will schedule them for the OR on an outpatient basis. So, when the service is an office diagnostic procedure, a rigid scope means you should report a 31231.

Flexible: A flexible scope allows better diagnostic views, is tolerated better by patients and can be performed in the office. "It is a pencil-thin, flexible fiber optic scope that goes in through the nose and then down the throat," Merrill says.

Example: An otolaryngologist documents a "direct laryngoscopy used to view the vocal cords by using a fiberoptic scope without taking a biopsy." In this case, you should code the procedure with 31575. Link the diagnostic code to the chief complaint, such as halitosis (784.99, Choking, sneezing, halitosis, mouth breathing).

ICD-10: When your diagnosis coding system changes in 2013, 784.99 will expand into four options, which you will choose based on your ENT's documentation:

• R06.5 -- Mouth breathing
• R06.7 -- Sneezing
• R06.89 -- Other abnormalities of breathing
• R19.6 -- Halitosis

Replace 31575 for Abnormal Findings

Diagnostic testing rules state that you should use the most specific diagnosis. So when your otolaryngologist finds a problem during a diagnostic scope, you should code the findings as your primary diagnosis and the complaints as your secondary diagnosis to better support the medical necessity.

For instance, the findings might specify a polyp, (478.4 Polyp of vocal cord or larynx), foreign body (933.1, Foreign body in pharynx), or lesion (478.29, Other disease of pharynx or nasopharynx). That means the physician would usually schedule a direct laryngoscopy for biopsy or removal under sedation for the outpatient OR.

ICD-10: When your diagnosis system changes in 2013, your diagnosis options will expand for 933.1:

• T17.300A -- Unspecified foreign body in larynx causing asphyxiation, initial encounter
• T17.308A -- Unspecified foreign body in larynx causing other injury, initial encounter
• T17.310A -- Gastric contents in larynx causing asphyxiation, initial encounter
• T17.318A -- Gastric contents in larynx causing other injury, initial encounter
• T17.320A -- Food in larynx causing asphyxiation, initial encounter
• T17.328A -- Food in larynx causing other injury, initial encounter
• T17.390A -- Other foreign object in larynx causing asphyxiation, initial encounter
• T17.398A -- Other foreign object in larynx causing other injury, initial encounter.
• For 478.29, you'll report J39.2 (Other diseases of pharynx).

If during a nasal scope for obstruction, the ENT found and removed a polyp, you would report 31237 (Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) instead of the diagnostic nasal scope (31231).