Pulmonology Coding Alert

If you find yourself fielding denials for 9921X with modifier 25 reported with diagnostic fiberoptic laryngoscopy, it could be time to change your reporting tactics.

Consider this scenario submitted by a subscriber:

"When I report 9921X (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), insurers keep bundling it into 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) even when I use separate diagnoses. I send in the documentation, but the evaluator doesn't think the pulmonologist's chart notes support a separate E/M. He includes one paragraph for the service and procedure and one for his impressions. Do you have any advice?"

Rolling the E/M and procedure descriptions and impressions into one paragraph makes it difficult for the representative to see that the pulmonologist had to perform the E/M to do the procedure, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. You can help solve this problem by encouraging your physician to write an impression and plan for the office visit that is separate from the laryngoscopy note.

Remember: A minor procedure's global package includes a small, related E/M. To report a service separately, documentation must show a history, examination and medical decision making that is more than the minor E/M associated with the procedure (i.e, above and beyond the typical management associated with the procedure).

Watch out: The E/M can't simply include the findings from the laryngoscopy. You can include findings from the manual viewing of the larynx in the E/M's examination portion to indicate the need for the laryngoscopy. But the findings from the laryngoscopy count toward the procedure. You can't count the laryngeal findings from the laryngoscopy under both the E/M exam and the laryngoscopy procedure note. Any management options or plan of treatment derived from the findings can be considered separate from the procedure since it is not part of the typical post-procedure service.

Here's an example of documentation for a stand-alone E/M service leading to the decision for laryngoscopy:

Subjective: A 63-year-old patient with obstructive bronchitis and emphysema returns to see his pulmonol-ogist. His symptoms of cough, mucus production and dyspnea continue, but he complains of the recent onset of hoarseness. The patient has had no recent respiratory infections and doesn't recall any episodes of aspiration. The patient takes Advair Diskus (one inhalation, twice daily) and averages four puffs of Combivent MDI a day.

Objective: Vital signs and general appearance are normal. Voice is hoarse without stridor. ENT exam shows clear external auditory canals and tympanic membranes. Intranasal exam shows a deviated septum to the right, but no intranasal masses or polyps. Oral exam is unremarkable and oropharynx is clear. Neck exam reveals that the trachea is normal and no increase in JVD. Chest exam shows low diaphragms which move 4 cm bilaterally. Breath sounds are decreased and rhonchi are present with forced aspiration. Heart exam shows NSR with normal S1 and S2 and no S3, S4 or murmurs. Abdomen is soft. No masses, organomegaly or tenderness is present. Extremities show no cyanosis, clubbing or edema. PFTs show moderately severe airflow limitation and are unchanged from the last testing six months ago.

Assessment: The patient's airway disease has showed no progression on current therapy, which will be continued. The recent onset of hoarseness is bothersome and needs evaluation.

Plan: Continue Advair Diskus one inhalation, twice daily. Use Combivent MDI as needed for wheezing and five minutes before exercise. Flu shot is needed in October. Flexible laryngoscopy is necessary to evaluate vocal cord structure and function. The risks and benefits of the procedure are explained to the patient, who agrees to the laryngoscopy and signs the consent form.

Procedure: Fiberoptic exam of nasopharynx, hypopharynx is negative. Fiberoptic laryngoscopy shows right true vocal cord paralysis with the right true cord in the abducted position. No obvious aspiration noted today. The patient tolerated the procedure well.

Impression: The patient has true vocal cord paralysis (478.32, Paralysis of vocal cords or larynx; unilateral, complete). In view of the patient's past history of smoking, lung cancer must be ruled out.

Plan: The patient will be scheduled for a non-contrast chest CT. If abnormal, a bronchoscopy will be necessary. This is discussed with the patient.

In this scenario, the physician evaluated and treated the patient for his obstructive bronchitis and emphysema. This was separate and distinct from the recent onset of hoarseness that required flexible laryngoscopy for evaluation. Submit both services and associated diagnoses separately:

• Report the initial visit with 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) and diagnoses 491.20 (Obstructive chronic bronchitis; without exacerbation) and 478.32 (Paralysis of vocal cords or larynx; unilateral, complete). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

• Code 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) for the laryngoscopy with diagnosis 478.32.

Note: Typically, the physician does not discuss procedure results and management options on the same day as the procedure, but it is possible for laryngoscopy.

Another example: A patient with long-standing asthma, generally well-controlled on his current medication, begins to complain of hoarseness. The physician exam shows normal vital signs and no heart murmur, though lungs exhibit an occasional wheeze. Oxygen saturation is 98 percent. The physician performs fiberoptic laryngoscopy. He visualizes the vocal cords and notes that they move well and that he does not see polyps or masses.

Why it works: "Here, the laryngoscopy was done to evaluate the hoarseness that was likely caused by the inhaled corticosteroid used to treat the asthma," explains Philip Marcus, MD, MPH, chief of the division of pulmonary medicine at St. Francis Hospital-The Heart Center in Roslyn, N.Y. "It was not done as part of asthma management and deserves to be paid as a separate procedure."

Even when your physician conducts separately-reportable services, know that appending modifier 25 doesn't guarantee payment. Medicare recognizes modifier 25 but might request additional documentation before issuing payment (partly because many providers have abused modifier 25). Private payers might not accept modifier 25 under any circumstances and might only pay for the procedure. Always know your payers' perspectives on modifier 25, how you should report those claims -- and what you can expect as reimbursement.