Otolaryngology Coding Alert

Using the wrong laryngoscopy code can be a costly error. A relatively simple procedure such as an indirect laryngoscopy (where no scope is used) can be confused with a far more complicated surgery because both codes describe laryngoscopies, with little in the CPT manual to distinguish them.

In fact, CPT lists 27 distinct laryngoscopy codes. Because there are so many, confusion about which code to use can occur, particularly if the otolaryngologist simply lists laryngoscopy at the top of the operative note. As a result, coders need to check the otolaryngologists documentation carefully not just the description of the procedure at the top of the operative report. This will ensure that the procedure performed will be the one billed.

Laryngoscopy Code Groups

The 27 codes can be divided into the following three groups:

indirect laryngoscopy
direct laryngoscopy
flexible laryngoscopy

Each of these groups, further, consists of four or more codes that differ by function, including but not limited to the following criteria:

diagnostic
with biopsy
with removal of foreign body
with removal of lesion

The reimbursement rates for these procedures vary greatly. For example, a diagnostic indirect laryngoscopy (31505, laryngoscopy, indirect; diagnostic [separate procedure]) has an assigned value of 2.14 relative value units (RVUs). A direct scope with arytenoidectomy (31561, laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope), the most expensive of the laryngoscopy procedures, has an assigned value of 9.90 RVUs.

This range of codes and corresponding payment rates means coders need to know how the three main laryngoscopy categories differ from each other. Further, coders need to
know how to recognize key words in the otolaryngologists operative report that point not only to the correct category but also to the specific procedure performed.

Indirect Laryngoscopy

Indirect laryngoscopy is the simplest of the three laryngoscopy categories. Consequently, the five procedures in this category do not involve a scope and offer the least reimbursement. Rather, they are used when the otolaryngologist examines the patient using mirrors to visualize the larynx, either for diagnostic purposes or as a guide for biopsy, lesion or foreign body removal, or vocal cord injection.

The simplest of these codes (diagnostic) often is used during a routine examination and should not be billed separately, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent coding and reimbursement specialist in Lakewood, N.J.

If the mirror is used to check on a specific condition or symptom, however, it may be billed separately. For example, a patient visits the doctor because of an earache (381.01, acute serous otitis media) but also complains of a sore tongue. The otolaryngologist evaluates the tongue using the mirror and determines the patient has glossitis (529.0).

Because the mirror exam is unrelated to the earache, 31505 can be billed separately. The appropriate level evaluation and management (E/M) service would be coded with a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached. Diagnosis code 381.01 would be linked to the E/M code, whereas the mirror exam would correspond to diagnosis code 529.0.

But, if a patient suffering from hoarseness (784.49) already had received a flexible laryngoscopy (31575, laryngoscopy, flexible fiberoptic; diagnostic), and during follow-up the otolaryngologist uses the mirror to inspect how the patient is doing, no E/M may be billed. The otolaryngologist can charge, however, for the 31505.

Other services performed via indirect laryngoscopy are:

31510 laryngoscopy, indirect; with biopsy

31511 laryngoscopy, indirect; with removal of
foreign body

31512 laryngoscopy, indirect; with removal of lesion

31513 laryngoscopy, indirect; with vocal cord
injection

Although these diagnostic procedures should not be reported if performed during the same session as a surgical endoscopy, they may be reported if an open surgical procedure is performed. In addition, 31511 may be billed separately if the procedure is performed during critical care of a patient.

Note: Indirect laryngoscopy with vocal cord injection uses both mirrors and a laryngoscope. The mirrors are used to examine the larynx and visualize the injection, which is then performed by a laryngoscope.

Key words. When an indirect laryngoscopy has been performed, coders should look for the following key words: indirect and mirror.

An indirect laryngoscopy should be coded 31505. Additional words such as biopsy, removal of foreign body or lesion, and vocal cord injection should direct the coder to choose either 31510, 31511, 31512 or 31513, as appropriate.

Flexible Laryngoscopy

The second category of laryngoscopy codes are used when a flexible fiberoptic scope is inserted through the patients nose or mouth to examine the interior of the larynx. These procedures offer unique information in the functional and anatomic assessment of the upper airway, according to a policy statement by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), and typically are performed in the otolaryngologists office.

The following codes should be used when a flexible laryngoscope is used for a biopsy or to remove a foreign body or lesion:

31575 laryngoscopy, flexible fiberoptic; diagnostic

31576 with biopsy

31577 with removal of foreign body

31578 with removal of lesion

Note: Code 31579 (laryngoscopy, flexible or rigid fiberoptic, with stroboscopy) typically is performed via flexible scope. In this procedure, the otolaryngologist shines a strobe light at the vocal cords to measure their function.

A growing number of otolaryngologists now use flexible laryngoscopy, also known as nasal pharyngeal laryngoscopy (NPL), in place of the mirror exam because it offers a much better look at the upper airway. As a result, however, more carriers are including 31575 as part of any accompanying E/M service, much like the mirror exam.

Place of service also should be checked in the operative report. If the procedure occurred in the office or at the bedside, it was either an indirect or flexible laryngoscopy.

Documentation Must Justify Scope During E/M

In a policy statement on flexible laryngoscopy, the AAO-HNS states, Flexible laryngoscopy should not be considered a routine part of the initial visit. In other words, it should not be used simply as a high-tech replacement for a mirror.

To get paid for a diagnostic flexible laryngoscopy performed on the same day as an E/M, the medical necessity of using the scope must be documented in the operative report. If the documentation shows that the otolaryngologist made the medical decision based on patient history and exam to perform a flexible laryngoscopy, the claim is far more likely to be paid, Cobuzzi says.

According to Cobuzzi, otolaryngologists unwittingly are helping carriers reject bills for flexible laryngoscopy performed at the same time as E/M services because they are documenting the NPL within the examination portion of the E/M service, bolstering the carriers claim that the laryngoscopy was part of the exam. The laryngoscopy findings should be listed separately from the E/M documentation, like a mini operative report. A second diagnosis, if borne out by the scope, also should be listed.

The solution, Cobuzzi says, is to keep the documentation of the E/M separate from that of the laryngoscopy. Otolaryngologists need to document taking the patients history, performing the examination and their medical decision-making on the basis of the visual examination, she explains. They need to ensure that the E/M service stands on its own without the NPLs findings.

If the otolaryngologist performs a thorough exam and decides to use the scope, he or she can bill for both by attaching modifier -25 to the E/M service, says Stella Almassian, administrator of the otolaryngology department at Northwestern University in Chicago. But Almassian says the procedure must be substantiated by documentation or it probably wont be paid.

If the documentation does not justify billing for both the 31575 and E/M, practices need to decide on when it is more appropriate to bill for the E/M or the scope. Almassian recommends billing for the scope rather than the E/M service only when the documentation supports such a claim. If the otolaryngologist scopes the patient and finds nothing, E/M should be billed. If something is revealed with the scope, its appropriate to bill the laryngoscopy.

Indications for Flexible Laryngoscopy During E/M

During the course of a complete examination, oto-laryngologists may perform a flexible laryngoscopy because the scope can examine areas that are inaccessible with the mirror or because the patient cannot tolerate the mirror due to a strong gag reflex. Gretchen Segado, CPC, chief compliance manager at Thomas Jefferson University in Philadelphia, and Randa Blackwell, a coding specialist with the department of otolaryngology at the University of Maryland in Baltimore, have created the following checklist of 10 indications for performing a flexible laryngoscopy.

1. Macroglossia preventing mirror examination
2. Gag reflex preventing mirror examination
3. Trismus preventing mirror examination
4. Patient unable to cooperate to allow mirror examination due to age (e.g., infants) or mental condition (mental retardation, dementia, etc.)
5. Hoarseness, dysphasia, aspiration not clearly evaluated by indirect laryngoscopy
6. Lesion identified by mirror examination needing further examination
7. Anterior commissure not completely visualized by mirror examination
8. Aspiration suspected that cannot be evaluated by mirror evaluation
9. Evaluation of the larynx and immediate subglottis in patients for tracheal decannulation
10. Acute airway obstruction evaluation

Note: Some of these indications may not provide medical necessity for all carriers. For instance, using flexible laryngoscopy because the patient has a gag reflex may be interpreted as a patient or physician convenience. Coders should check with the individual carrier regarding this issue.

Flexible Laryngoscopy and Sinus Endoscopy

Because the flexible laryngoscope typically is passed through the nose, the sinus area can be examined before the scope enters the larynx. In other words, a nasal/sinus endoscopy as well as a flexible laryngoscopy may be performed. In these circumstances, however, both procedures cannot be billed.

Code 31231 (nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) or 31237 (nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]) could be converted to 31575, for example, when examining a patient who has sinus problems but also has indications for gastro-esophageal reflux disease (GERD), Cobuzzi says.

In addition, both 31231 and 31237 may be converted to 31576 if a biopsy is taken or 31578 if a lesion is removed.

Key words. The following key words help coders recognize when a flexible laryngoscopy has been performed: flexible, fiberoptic and NPL.

A flexible laryngoscopy should be coded 31575. Additional words such as biopsy, removal of foreign body or removal of lesion should direct the coder to use either 31576, 31577 or 31578, as appropriate.

Direct Laryngoscopy

Although flexible laryngoscopy is useful for diagnostic purposes, more complex scoping procedures often need to be performed using direct laryngoscopy, which almost always takes place in the operating room (OR).

The flexible laryngoscopy might identify a problem that requires better instrumentation to obtain a more complete picture. For example, an otolaryngologist examining a patient with swallowing difficulties (787.2, dysphagia) might perform a flexible laryngoscopy that determines there is a problem. But due to difficulties in performing a biopsy because of the location of the problem, the patient is scheduled for the OR to have a direct laryngoscopy. An operating microscope also will be used.

When direct laryngoscopy is performed, the otolaryngologist is able to see the throat through the scope, which goes into the mouth and down the larynx of the sedated patient.

This laryngoscopy category is the largest (17 codes) and involves the most complex procedure. In addition, there are separate codes depending on whether microlaryngoscopy (i.e., direct laryngoscopy with operating microscope) is performed. For example, a diagnostic direct laryngoscopy has a different code (31525) than a diagnostic direct laryngoscopy performed with an operating microscope (31526).

Other services that may be part of a direct laryngoscopy and performed with or without a microscope include:

31530 laryngoscopy, direct, operative, with foreign
body removal; without operating microscope

31531 laryngoscopy, direct, operative, with foreign
body removal; with operating microscope

31535 laryngoscopy, direct, operative, biopsy;
without microscope

31536 laryngoscopy, direct, operative, biopsy; with
operating microscope

31540 laryngoscopy, direct, operative, with excision
of tumor and/or stripping of vocal cords or epiglottis; without microscope

31541 laryngoscopy, direct, operative, with excision
of tumor and/or stripping of vocal cords or epiglottis; with operating microscope

31560 laryngoscopy, direct, operative, with arytenoidectomy, without microscope

31561 laryngoscopy, direct, operative, with
arytenoidectomy, with operating microscope

31570 laryngoscopy, direct, with injection into vocal
cord(s), therapeutic, without microscope

31571 laryngoscopy, direct, with injection into vocal
cord(s), therapeutic, with operating microscope

The highest-paying code, 31561, has a value of 9.90 RVUs and involves the removal of the arytenoid cartilage, which plays a role in the functioning of the vocal cords.

Note: Microlaryngoscopy procedures pay slightly more than their non-microscope equivalents. For example, removal of foreign body via microlaryngoscopy (31531) is valued at 5.98 RVUs, slightly more than 31530 (5.35 RVUs).

The following codes are for services performed via a direct laryngoscopy have their own codes:

31515 laryngoscopy, direct, with or without
tracheoscopy; for aspiration

31520 laryngoscopy, direct, with or without
tracheoscopy; diagnostic, newborn

31527 laryngoscopy, direct, with or without
tracheoscopy; with insertion of obturator

31528 laryngoscopy, direct, with or without
tracheoscopy; with dilatation, initial

31529 laryngoscopy, direct, with or without
tracheoscopy; with dilatation, subsequent

Note: The most commonly performed direct laryngoscopies are 31535, 31536 and 31541.

If a procedure began as an indirect or flexible laryngoscopy and had to be converted to a direct scope, only the direct scope may be billed. If, in such cases, an appropriate E/M service that meets the 10 indications outlined earlier in this article is performed, a modifier needs to be attached. For Medicare carriers, modifier
-25 should be used. But some private carriers ask providers to use modifier -57 (decision for surgery) when billing E/M with the direct laryngoscopy, even though all laryngoscopy procedures have 0 global days.

Direct laryngoscopies usually take place in the OR, whereas flexible and indirect laryngoscopies usually are performed in the otolaryngologists office or at the patients bedside. In addition, only direct laryngoscopy codes include the use of the operating microscope. Therefore, if the procedure took place in the OR and the operative note also reports that an operating microscope was used, the coder can determine that in all likelihood, a direct microlaryngoscopy was performed.

Key words. The following key words help coders recognize when a direct laryngoscopy was performed: operating room or OR, operating microscope, microscope, microlaryngoscopy and direct.

If the procedure was performed for more than diagnostic purposes, the following key words may offer clues as to what procedure was performed: aspiration, newborn, obturator, dilatation, foreign body removal, biopsy, excision of tumor, stripping of vocal cords, epiglottis, arytenoidectomy, and vocal cord injection.