Otolaryngology Coding Alert

Code 787.20 comes to the rescue when ENT can't discern problem stage

When four specific dysphagia phase codes go into effect this fall, don't fret if you find yourself opting more often than not for an NOS code. Although using 787.20 won't usually affect payment, make sure you know when to get specific.

Pinpoint Specific Phase With 787.21-787.24
 
Give your ENT and speech language therapists the heads up they-ll need to include the specific type of dysphagia in patients- charts. More important, make sure you set up your computer system to red flag the use of 787.2 (Dysphagia) as an invalid and truncated code. The 2008 update deletes that code and replaces it with five-digit codes (787.20-787.29) that correspond with the following new dysphagia phases:

- oral (787.21)
- oropharyngeal (787.22)
- pharyngeal (787.23)
- pharyngoesophageal (787.24).

New Codes, New Benefits

Using the specific code when available might help justify billing two procedures, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. Insurance companies are usually looking for a specific diagnosis only when the treatment is specific to a location or disease process.

For instance, an otolaryngologist performs a dilation for pharyngoesophageal dysphagia (43220, Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]) and biopsies a true vocal cord lesion (31535, Laryngoscopy, direct, operative, with biopsy). Using the specific dysphagia diagnosis and the biopsy diagnosis--such as 787.21 for oral dysphagia with 161.0 (Malignant neoplasm of larynx; glottis)--will help justify medical necessity for both scopes.

Default to NOS Code for -Dysphagia-

When the medical record makes no distinction other than the diagnosis -dysphagia,- you will have to report 782.20 for -Dysphagia, unspecified,- says Steven C. White, PhD, director of healthcare economics and advocacy for the American Speech-Language-Hearing Association (ASHA) in Rockville, Md. The otolaryngologist could use this as the general diagnosis to identify the reason a patient needs to see a speech-language pathologist for a more definitive diagnosis.

You might classify more claims than you expect to the not otherwise specified (NOS) code. When a patient is not very good at describing his symptoms during an initial dysphagia evaluation, the otolaryngologist might not be able to discern which specific dysphagia code to use (787.21-787.24), Callaway says.

Good news: In these cases, you don't need to ask the ENT for clarification, Callaway says. -Unless you are billing a procedure on a specific body area that requires a specific matching diagnosis,- the payer shouldn't reject the claim due to using an NOS code.

Relegate Outlier Dysphagia Dxs to 787.29

If following an evaluation the dysphagia doesn't fall into one of the four new dysphagia phases, opt for 787.29 (Other dysphagia), which is a not elsewhere classified (NEC) code. Unlike 782.20, which indicates that the medical record doesn't identify the specific phase, 787.29 says the physician made the diagnosis but it's outside the options ICD-9 lists.

ICD-9 has long-term interests in mind when creating NEC codes. Code 787.29 will allow for future cases in which a provider may diagnose a patient with a type of dysphagia that is not classifiable to any of the specific codes, but it is a specific type. -The National Center for Health Statistics will be indexing the following terms to 787.29 other dysphagia: cervical dysphagia and neurogenic dysphagia,- White tells Otolaryngology Coding Alert.

Stress Lymphoma Dxs Must Identify Affected Area

Of the 54 new lymphoma codes that become effective this October, you-ll need to focus on 12 of them. Make sure your otolaryngologist's documentation specifies the type of lymphoma as well as the body part it affects. That information will be essential next fall.

The new ICD-9 diagnoses include lymphoma codes for:

- marginal zone lymphoma (200.30-200.38)
- mantle cell lymphoma (200.40-200.48)
- primary central nervous system lymphoma (200.50-200.58)
- anaplastic large cell lymphoma (200.60-200.68)
- large cell lymphoma (200.70-200.78)
- peripheral T-cell lymphoma (202.70-202.78).

Each subcategory requires you to specify whether the lymphoma is in the head, face or neck; the intrathoracic lymph nodes; the intra-abdominal lymph nodes; upper limb; lower limb; intrapelvic; spleen; or multiple sites. Otolaryngology coders can zoom in on the -1- fifth-digit code in each group to represent:

- 200.31: Marginal zone lymphoma, lymph nodes of head, face, and neck
- 200.41: Mantle cell lymphoma, lymph nodes of head, face, and neck
- 200.51: Primary central nervous system lymphoma, lymph nodes of head, face, and neck
- 200.61: Anaplastic large cell lymphoma, lymph nodes of head, face, and neck
- 200.71: Large cell lymphoma, lymph nodes of head, face, and neck
- 202.71: Peripheral T cell lymphoma, lymph nodes of head, face, and neck.

For multiple sites, use the fifth-digit subclassification of 8.

Each type of lymphoma requires a very different treatment, says independent consultant Margaret Hickey in New Orleans. So with these new, more specific diagnosis codes, you-ll have to be more careful to align each drug with the appropriate diagnosis code.