Otolaryngology Coding Alert

Question: A physician performed a laryngoscopy (31541) on a patient with a polyp of vocal cord (478.4). The patient smoked two packs a day and also chewed tobacco. The physician performed an esophagoscopy (43200). Medicare denied the 43200, and I appealed. It was denied again, and our carrier referred to a December 1997 bulletin that stated that Medicare will not pay for screenings performed in the absence of signs or symptoms. A vocal cord polyp is not a covered diagnosis for an esophagoscopy, and the carrier reviewed the office notes and dictation and decided the service was not reasonable and necessary. Can you advise?

New Mexico Subscriber  
Answer: Most Medicare carriers have issued a list of payable diagnoses for a variety of esophagoscopy and upper gastrointestinal endoscopic procedures, and, unfortunately, if the diagnosis the otolaryngologist provided is not on the list, the carrier will not pay for the service.
 
Unlike the bundling of bronchoscopy and laryngoscopy, which is an edit in the national Correct Coding Initiative, the esophagoscopy is denied on the basis of the diagnosis. The patient may well have had dysphagia (787.2), but if the doctor didn't document it, it can't be included.
 
But performing the esophagoscopy on a patient with a polyp on the vocal cord is considered good medical practice, which could be the basis for an independent Fair Hearing appeal, because laryngeal cancer sometimes spreads to the nearby bronchi or esophagus. You might lose the appeal, but what have you lost? You don't need to hire a lawyer, you just need to write a letter.
 
Also, a diagnosis of 989.84 (toxic effects of tobacco) could be used to justify the esophagoscopy because the patient chewed tobacco.
 
This diagnosis should not be confused with 305.1 (tobacco use disorder; tobacco dependence) or V15.82 (history of tobacco use). In particular, otolaryngologists who are not treating the patient's addiction to tobacco should not use 305.1, which is in the psychiatric section of the ICD-9 book. Rather, they are treating the physical effects of tobacco, and this is appropriately reported using 989.84.