Otolaryngology Coding Alert

Chart note tests your modifier -25 knowledge

You can avoid payers denying an office visit or consultation billed with a laryngoscopy, if documentation includes separate 99201-99215/99241-99275 and 31575 impression notes.

When billing an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) or a consultation (99241-99275) with flexible laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic), you can't automatically 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 the E/M service. "Documentation has to justify billing an E/M with the procedure," says Jolene Eicher, practice manager at Commonwealth Ear, Nose and Throat, which has seven otolaryngologists in Louisville, Ky.

Rule: You should bill 99201-99215 or 99241-99275 in addition to 31575 only when your otolaryngologist documents that he performed a significant, separately identifiable history, examination and medical decision-making from the minor E/M the laryngoscopy includes.   

Challenge: See if you can recognize documentation that supports a separate E/M with a real-world chart note: 
 
More Than Minor E/M Justifies Service Billing Zero-day global codes, such as 31575, include a minor related pre- and postoperative E/M, according to global surgery rules. But a medically necessary significant, separately identifiable history, examination and medical decision-making makes service justification easier, as the following documentation shows:

Case 1: Ms. Smith is a 64-year-old whom I saw in hospital consultation for dysphagia, vocal chord paralysis, hoarseness and intermittent aspiration. She also has hyperparathyroidism and has had a parathyroidectomy. She had vocal chord paralysis during that operation and has had hoarseness and aspiration problems since then. She is here with her daughter and they want my opinion on whether she needs further surgery as her surgeon suggests.

Past history: Gastroesophageal reflux disease, depression, congestive heart failure, arthritis, cornea disease and hyperparathyroidism.

Current medications: Include Lasix, potassium, Norvasc, Altace, Prevacid, Effexor, Serax, Singulair, Colace, Vicodan.

Allergies: Allergic to Codeine. Nonsmoker.

Review of systems: Otherwise negative.

I performed a comprehensive head and neck examination. General appearance is normal. The patient is in no distress. She is hoarse but I note no stridor. External canals and tympanic membranes are clear. lntranasal exam shows deviated septum to the right but no intranasal masses or polyps. Oral exam is negative. Oropharynx is clear. Fiber optic exam of nasopharynx, hypopharynx is negative. Fiberoptic laryngoscopy shows right true vocal cord paralysis, but the right true cord is in fairly good midline position and the left approximates it well on phonation. No obvious aspiration noted today. Neck exam shows previous surgical scar and no other palpable masses, adenopathy or hyromegaly.

Impression: True vocal cord paralysis and associated hoarseness and dysphagia with intermittent aspiration. The vocal cord on the right is fairly well medialized, and [...]