Otolaryngology Coding Alert

Question: Our otolaryngologist saw a new patient with a chief complaint of postnasal drip and difficulty breathing through their nose. The patient used to smoke cigarettes but quit several years ago. The E/M service lasted 37 minutes and involved low-level medical decision making (MDM). Based on the exam, the ENT ordered a CT to confirm the diagnosis before suggesting treatment. A separate facility performed and interpreted the CT. The final diagnosis for this patient was nasopharyngeal polyp. How should I report this encounter?

Delaware Subscriber

Answer: You can use time to code the otolaryngologist’s evaluation and management (E/M) service in this case. Report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the E/M.

The facility performing the computerized tomography (CT) scan may separately bill that service.

The primary diagnosis code for this case is J33.0 (Polyp of nasal cavity). You should use this code if you see the term “choanal polyp” or “nasopharyngeal polyp” in the note. Since the patient used to smoke, you’ll need to report Z87.891 (Personal history of nicotine dependence), as well.