Pulmonology Coding Alert

These tips will help stop 9921X and 31575 bundlingIf you find yourself fielding denials for 9921X with modifier 25 reported with diagnostic fiberoptic laryngoscopy, it could be time to change your reporting tactics.Consider this scenario submitted by a subscriber:"When I report 9921X (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), insurers keep bundling it into 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) even when I use separate diagnoses. I send in the documentation, but the evaluator doesn't think the pulmonologist's chart notes support a separate E/M. He includes one paragraph for the service and procedure and one for his impressions. Do you have any advice?"Start With SeparationsRolling the E/M and procedure descriptions and impressions into one paragraph makes it difficult for the representative to see that the pulmonologist had to perform the E/M to do the procedure, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. You can help solve this problem by encouraging your physician to write an impression and plan for the office visit that is separate from the laryngoscopy note.Remember: A minor procedure's global package includes a small, related E/M. To report a service separately, documentation must show a history, examination and medical decision making that is more than the minor E/M associated with the procedure (i.e, above and beyond the typical management associated with the procedure).Watch out: The E/M can't simply include the findings from the laryngoscopy. You can include findings from the manual viewing of the larynx in the E/M's examination portion to indicate the need for the laryngoscopy. But the findings from the laryngoscopy count toward the procedure. You can't count the laryngeal findings from the laryngoscopy under both the E/M exam and the laryngoscopy procedure note. Any management options or plan of treatment derived from the findings can be considered separate from the procedure since it is not part of the typical post-procedure service.See How It WorksHere's an example of documentation for a stand-alone E/M service leading to the decision for laryngoscopy:Subjective: A 63-year-old patient with obstructive bronchitis and emphysema returns to see his pulmonol-ogist. His symptoms of cough, mucus production and dyspnea continue, but he complains of the recent onset of hoarseness. The patient has had no recent respiratory infections and doesn't recall any episodes of aspiration. The patient takes Advair Diskus (one inhalation, twice daily) and averages four puffs of Combivent MDI a day.Objective: Vital signs and general appearance are normal. Voice is hoarse without stridor. [...]