Otolaryngology Coding Alert

How to combat a key ENT problem You can get payers to cover diagnostic scopes, such as nasopharyngoscopy, nasal endoscopy and laryngoscopy, with an E/M service. Just make sure that the visit warrants modifier -25, the documentation supports a separate service, and the insurer doesn't impose frequency restrictions, coding experts say.

Getting payers to cover nasal endoscopy (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) with an office visit (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) is one of the biggest problems for Margie Gittelman, office manager at Paul Gittelman, MD, FACS, in Mamaroneck, N.Y. "Some insurers, such as Cigna, will pay after I write an appeal letter," she says.
 
Many third-party payers don't want to pay for both an office visit and a scope, says Teresa Thompson, CPC, CCC, a nationally recognized speaker on otolaryngology coding, compliance and reimbursement and president of TM Consulting in Carlsburg, Wash.

Don't give up, Thompson says. To combat E/M-scope denials, coding experts offer the following four tips: 1. Know What Justifies Modifier -25 First, make sure that the office visit is separately reportable, Thompson says. Remember: Just because you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to an E/M service doesn't justify its use.

The National Correct Coding Initiative includes a related pre- and postoperative E/M with codes that contain zero global days, such as 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). Therefore, you should only report an office visit that qualifies as a significant, separately identifiable service from the scope.

For instance, a new patient complains of hoarseness (784.49). The otolaryngologist performs and documents a history, examination and medical decision-making. Based on his findings, he decides a laryngoscopy is necessary and separately documents the procedure. The scope doesn't reveal any problems, such as a polyp (478.4, Polyp of vocal cord or larynx). But, because the otolaryngologist performed a separate history, examination and medical decision-making from that included in the laryngoscopy, the visit meets modifier -25's definition. Therefore, you should report 9920x-25 (Office or other outpatient visit for the E/M of a new patient ...) in addition to 31575.

2. Get Your ENT to Write Separate Notes You should also encourage your otolaryngologist to document the exam and scope on different pages, Thompson says. To show payers that the E/M service led to the diagnostic procedure, encourage your otolaryngologist to write the history, examination and medical decision-making on page one under the examination note. He should then detail the reason for the scope as well as all associated findings on page two in the procedure note.

Physically separating the service and procedure will [...]