Part B Insider (Multispecialty) Coding Alert

Check out this handy list of 10 scope indications.

When your physician performs an E/M service along with a laryngoscopy, you cannot always report both services. Unless your doctor provides a mini operative report of the scope’s findings, then you can bet you’ll only be paid for one of these services.

Here’s how to tackle this problem and how to solve it — once and for all.

Identify The Scope and E/M Service Issue

Background: In a policy statement on flexible laryngoscopy, the AAO-HNS states, “Flexible laryngoscopy should not be considered a routine part of the initial visit.” In other words, it should not be used simply as a high-tech replacement for a mirror.

To get paid for a diagnostic flexible laryngoscopy performed on the same day as an E/M, the medical necessity of using the scope must be documented in the operative report. If the documentation shows that the otolaryngologist made the medical decision based on patient history and exam to perform a flexible laryngoscopy, the claim is far more likely to be paid, experts say.

Otolaryngologists unwittingly are helping carriers reject bills for flexible laryngoscopy performed at the same time as E/M services because they are documenting the flexible laryngoscopy within the examination portion of the E/M service, bolstering the payer’s claim that the laryngoscopy was part of the exam. The laryngoscopy findings should be listed separately from the E/M documentation, like a mini operative report. A second diagnosis, if borne out by the scope, also should be listed.

Jump on Board With This Solution

The solution is to keep the documentation of the E/M separate from that of the laryngoscopy. Otolaryngologists need to document taking the patients history, performing the examination and their medical decision-making on the basis of the visual examination, she explains. They need to ensure that the E/M service stands on its own without the flexible laryngoscopy’s findings.

If the otolaryngologist performs a thorough exam and decides to use the scope, he or she can bill for both by attaching modifier 25 to the E/M service. The procedure must be substantiated by documentation, or it probably won’t be paid.

If the documentation does not justify billing for both the 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) and E/M, practices need to decide on when it is more appropriate to bill for the E/M or the scope. Bill for the scope rather than the E/M service only when the documentation supports such a claim. If the otolaryngologist scopes the patient and finds nothing, you should report the E/M. If something is revealed with the scope, then you should bill the laryngoscopy.

Indications for Flexible Laryngoscopy During E/M

During the course of a complete examination, otolaryngologists may perform a flexible laryngoscopy because the scope can examine areas that are inaccessible with the mirror or because the patient cannot tolerate the mirror due to a strong gag reflex. Here is a checklist of 10 indications for performing a flexible laryngoscopy:

1.   Macroglossia preventing mirror examination

2.   Gag reflex preventing mirror examination

3.   Trismus preventing mirror examination

4.   Patient unable to cooperate to allow mirror examination due to age (e.g., infants) or mental condition (mental retardation, dementia, etc.)

5.   Hoarseness, dysphasia, aspiration not clearly evaluated by indirect laryngoscopy

6.   Lesion identified by mirror examination needing further examination

7.   Anterior commissure not completely visualized by mirror examination

8.   Aspiration suspected that cannot be evaluated by mirror evaluation

9.   Evaluation of the larynx and immediate subglottis in patients for tracheal decannulation

10. Acute airway obstruction evaluation

Note: Some of these indications may not provide medical necessity for all payers. For instance, using flexible laryngoscopy because the patient has a gag reflex may be interpreted as a patient or physician convenience. Coders should check with the individual payer regarding this issue.