Can some one please help me with what this procedure docmentation should look like? We have a provider whom is billing out this procedure in the office along with an e/m visit. From the information i am getting from the staff the instrument used has light on the end. The staff indicates the instrument does not have a rod that is inserted. Just want to clarify and justify what the doctor is acutally performing
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31231 help
- Thread starter kerileigh
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OCD_coder
True Blue
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- Columbia, TN
It would probably help us better if you could type the procedure note so we can review the documentation for you. An endoscopy, diagnostic has nothing to do with whether there is a light at the end or not, it's the provider simply scoping to diagnose the problem the patient is having. So basically a description of using the scope and identification of the structures and what he see's is pretty much all that we can require.
Here is a description from one of my procedures books for you to review.
The physician uses an endoscope for a diagnostic evaluation of the nose. An endoscope has a rigid fiberoptic telescope that allows the physician both increased visualization and magnification of internal anatomy. Topical vasoconstrictive agents are applied to the nasal mucosa and nerve blocks with local anesthesia are performed. The endoscope is placed into the nose and a thorough inspection of internal nasal structures is accomplished. No surgical procedure is performed. I]
Here is a description from one of my procedures books for you to review.
The physician uses an endoscope for a diagnostic evaluation of the nose. An endoscope has a rigid fiberoptic telescope that allows the physician both increased visualization and magnification of internal anatomy. Topical vasoconstrictive agents are applied to the nasal mucosa and nerve blocks with local anesthesia are performed. The endoscope is placed into the nose and a thorough inspection of internal nasal structures is accomplished. No surgical procedure is performed. I]
Here is an example: Nasal/Sinus Endoscopy Rigid:
After discussing the risks, limitations, potential benefits, and alternatives, the patient agreed to the procedure, and consent was given.
Indications for use of fiberoptic examination and treatment: Chronic sinusitis
and/or other reasons: __________________________________.
Fiberoptic endoscopy of the left and right nasal cavity and nasapharynx was performed in a systematic fashion.
Findings/Impression: pale boggy mucosa
The patient tolerated the procedure well.
Date scope was disinfected:January 22014
Type of scope(s) used: Rigid
Serial Number of Scope: 2
Name of nurse(s) cleaning scope(s):___________________
Name of nurse(s) assisting:___________________
My next question is the actual instrument itself, from what i am understanding from the staff is the instrument being used is not a telescope??
After discussing the risks, limitations, potential benefits, and alternatives, the patient agreed to the procedure, and consent was given.
Indications for use of fiberoptic examination and treatment: Chronic sinusitis
and/or other reasons: __________________________________.
Fiberoptic endoscopy of the left and right nasal cavity and nasapharynx was performed in a systematic fashion.
Findings/Impression: pale boggy mucosa
The patient tolerated the procedure well.
Date scope was disinfected:January 22014
Type of scope(s) used: Rigid
Serial Number of Scope: 2
Name of nurse(s) cleaning scope(s):___________________
Name of nurse(s) assisting:___________________
My next question is the actual instrument itself, from what i am understanding from the staff is the instrument being used is not a telescope??
prayercoder
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- Montgomery, AL
31231 with E/M visit
2014 Optum "Coder's Desk Reference Procedures" describes 31231 as follows: "The physician uses an endoscope for a diagnostic evaluation of the nose. An endoscope has a rigid fiberoptic telescope that allows the physician both increased visualization and magnification of internal anatomy. Topical vasoconstrictive agents are applied to the nasal mucosa and nerve blocks with local anesthesia are performed. The endoscope is placed into the nose and thorough inspection of internal nasal structures is accomplished. No surgical procedure is performed."
Document: pre-procedure diagnosis and reason for procedure, all the usual possible complications, etc. Document size of scope, type of scope, whether done bilaterally or unilaterally, name of vasoconstrictive agents and or medication for nerve block if done. Describe normal and abnormal findings of nasal structures such as septum, turbinates, mucosa, etc. Indicate how procedure was tolerated and if any complications occurred. Document post procedure diagnosis.
It sounds like you are asking if an E/M visit can be billed with this procedure. Read about modifier 25 in your CPT book. There must be adequate documentation of the office visit to specify that a significantly separate identifiable evaluation and management service was provided above and beyond the endoscopy. If an identifiable E/M service is documented it should be billed with a 25 modifier to indicate this.
In other words, if the only reason the patient came to the office was the endoscopy and no separate E/M services were provided, only the endoscopy can be billed.
Hope this helps.
2014 Optum "Coder's Desk Reference Procedures" describes 31231 as follows: "The physician uses an endoscope for a diagnostic evaluation of the nose. An endoscope has a rigid fiberoptic telescope that allows the physician both increased visualization and magnification of internal anatomy. Topical vasoconstrictive agents are applied to the nasal mucosa and nerve blocks with local anesthesia are performed. The endoscope is placed into the nose and thorough inspection of internal nasal structures is accomplished. No surgical procedure is performed."
Document: pre-procedure diagnosis and reason for procedure, all the usual possible complications, etc. Document size of scope, type of scope, whether done bilaterally or unilaterally, name of vasoconstrictive agents and or medication for nerve block if done. Describe normal and abnormal findings of nasal structures such as septum, turbinates, mucosa, etc. Indicate how procedure was tolerated and if any complications occurred. Document post procedure diagnosis.
It sounds like you are asking if an E/M visit can be billed with this procedure. Read about modifier 25 in your CPT book. There must be adequate documentation of the office visit to specify that a significantly separate identifiable evaluation and management service was provided above and beyond the endoscopy. If an identifiable E/M service is documented it should be billed with a 25 modifier to indicate this.
In other words, if the only reason the patient came to the office was the endoscopy and no separate E/M services were provided, only the endoscopy can be billed.
Hope this helps.
Last edited:
Candice_Fenildo
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- Port Saint Lucie, FL
kerileigh
I can email you templates from my office on the different sinus endoscope procedures if you would like?
I kept the hard copies before we went live on EHR 7 years ago because it is a good learning tool for others.
Feel free to email me @ cruffing@otodocs.com
or my email below and I will email you the attachments as well as the pages from the ENT Coding Companion from Ingenix.
I can email you templates from my office on the different sinus endoscope procedures if you would like?
I kept the hard copies before we went live on EHR 7 years ago because it is a good learning tool for others.
Feel free to email me @ cruffing@otodocs.com
or my email below and I will email you the attachments as well as the pages from the ENT Coding Companion from Ingenix.