Otolaryngology Coding Alert

Your endoscopy coding needs an overhaul if you get these answers wrong Get the lowdown on documentation requirements for an E/M or scope following sinus surgery with septoplasty so you don't bundle separately reportable items into the global period. Review the Documentation On Aug. 1, an otolaryngologist performed a septoplasty (30520) with 90 global days, as well as bilateral total ethmoidectomies (31255) and maxillectomy with tissue removal (31267), which have zero global days. See if you can tell what to break out and what to include in the following Aug. 14 office note: Vital signs: Height: 68 in. Tobacco use: quit 10 years ago (PFSH-social) Allergies reviewed - no changes (PFSH-history) Office note: Chief complaint: Patient returns to the office today in FU, status postnasal septoplasty, bilateral total ethmoidectomies and left maxillary sinusotomy with tissue removal. History of present illness: Patient reports ongoing (HPI-duration) "sinus headaches" (HPI-associated signs and symptoms). She denies any purulent rhinorrhea (ROS-ENT) or fevers (ROS-constitutional). She does remind me that she has multiple types of headaches, including migraines, etc. (HPI-severity) She indicates that she is irrigating 2-3 times per day (HPI-modifying factors). Physical examination: Anterior rhinoscopy reveals clear nose and midline septum (nose included in septoplasty's global package). Examined endoscopically patient's sinuses, including ethmoid sinuses bilaterally and left maxillary sinus (included in endoscopic exam). The patient's sinus surgery defects are healing nicely. There is no evidence of any infection, bleeding, etc. (findings included in endoscopy). Impression: Satisfactory postoperative course. Recommendations: Patient will continue to irrigate at least two times per day. We have asked her to return to see us on the three-month anniversary of surgery, some time in late September. Procedure note: Procedure: Nasal/sinus endoscopy; bilateral ethmoid and left maxillary sinus endoscopy. Anesthesia: Topical Lidocaine. Findings: Included . Procedure: Following adequate Lidocaine spray analgesia, inspected using the fiberoptic endoscope the patient's nasal cavities bilaterally, ethmoid cavities bilaterally and left maxillary sinus. Notes the above findings. Patient tolerated the procedure well. No complications. Stop Assuming E/M Is Never Credible Question 1: Should the doctor report an E/M service? The above office note has an expanded problem-focused history (HPI: 4-Extended; ROS: 2-Extended; PFSH: past, social 2-Complete) but no physical examination or medical decision-making that stands separate from the scope's minor included E/M. "I do not see enough documentation that would substantiate an E/M," says Michelle Logsdon, CPC, CCS-P, PCS, Falcon Practice Management in Toms River, N.J. "More detail needs to be there to show me that the decision for the procedure was secondary to the actual visit," says Suzan Hvizdash, CPC, CPC-E/M, CPC-ED, medical auditor for the University of Pittsburgh Physicians. Although the patient mentioned headaches, the physician made no further documentation to support an E/M and [...]