Otolaryngology Coding Alert

How to protect your 9921x-25 pay

If you're billing laryngoscopy with established patient visits, get ready for lots of payer scrutiny.

Increasingly, major payers are asking to review in-office laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic) claims that contain an established patient office visit (99212-99215, Office or other outpatient visit for the E/M of an established patient ...). Even worse, some insurers are requesting automatic E/M repayments.

Here's how to find out if you're a target and what you can do to protect your laryngoscopy pay. Who's at Risk You'd better be ready for other payers to follow Indiana and Kentucky Medicare's lead and start questioning the validity of established patient office visits billed with laryngoscopy. "Is anyone receiving requests for insurance reviews from Medicare and Blue Cross for laryngoscopy done in the office?" asks Stephanie Staples, coding specialist at Kentucky Ear, Nose and Throat, which has four otolaryngologists.

Problem: Indiana and Kentucky's Medicare carrier started targeting ENT practices based on 31575 and modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) established E/M visit billing patterns. Administar Federal, Indiana and Kentucky's Part B carrier, is now asking otolaryngologists to repay any established visit reimbursement that they billed in addition to the diagnostic laryngoscopy, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J. "The carrier is assuming the encounters didn't warrant modifier -25."

Out: Each practice in Indiana and Kentucky can appeal the recoupments. Expect plenty of scrutiny if you choose to appeal. The insurer will audit each chart to see if documentation supports using modifier -25, Cobuzzi says. Before you decide to appeal, you must decide whether your documentation supports an established patient E/M with a laryngoscopy. Which Cases Withstand Scrutiny Whenever you bill 99212-99215 with 31575, the visit must qualify as a significant, separately identifiable E/M service from the laryngoscopy. Remember, even minor procedures contain a minor related pre- and postoperative E/M, such as prepping the patient and issuing any findings. So to report an established patient E/M in addition to the laryngoscopy, the otolaryngologist must perform a significant, separately identifiable history, examination and medical decision-making from the procedure's.

Key: Documentation must clearly show that the visit meets modifier -25 criteria. Separate chart and procedure notes will help substantiate the E/M from the laryngoscopy.

The chart note should identify the significant, separate E/M. "In the first paragraph, the otolaryngologist should document a history, an exam and the medical decision-making that lead to the decision to perform the scope," Cobuzzi says. He should write the procedure note in a separate paragraph. "This way you can actually [...]