Wiki 31575 anatomy components required of suggested?

[wynonna]

31575 anatomy components:

From procedure section of note:
Nasal cavity: There is no evidence any polyps, purulence, or exudate. Septum was deviated to the left but the airway was adequate.
Nasopharynx: Nasopharynx was open and clear and free of any neoplastic changes. Eustachian tube orifices were patent. There is no evidence of a postnasal drip.
Oropharynx: The oropharynx was symmetric and free of any neoplastic changes. Her tonsils had been removed.
Supraglottic larynx: There was no evidence of any swelling, erythema, or neoplastic changes. The region was symmetric.
Larynx: The vocal cords moved but closure was modified by the presence of a 2 to 3 mm white nodule at the junction of the anterior third and posterior two thirds of the right vocal cord. The left vocal cord was free of any lesions. There was no evidence of any other changes. There was no clear evidence of any ongoing changes suggestive of reflux.
Hypopharynx: There was no pooling in the piriform sinuses which opens well.

tongue protrusion is noted in EXAM

Question: Does anything seem missing from 31575 description on MD note per CPT? If so, If a component or 2 was missing, do I add mod 52? Are components mentioned on page 215 of CPT, 2024 Endoscopy section recommended or required documentation?

Thank you fellow ENT coders

 

[nsteinhauser]

Before these findings were listed, does the doctor mention "flexible larygoscopy" or "flexible fiberoptic laryngoscope was used"? I think that needs to be stated somewhere.
You and I know that you can't 'visualize' these anatomical components without a scope, but the payers want it stated/indicated somewhere that a scope (or whatever instrumentation) was used.

 

[wynonna]

Yes, he does. "Procedure: In order to appropriately evaluate the pharynx and larynx given her severe gag reflex a fiberoptic laryngoscopy was performed. Both nostrils were sprayed with Lidocaine 4% mixed with Afrin. The endoscope was placed into right nostril with the patient sitting up position. "
Can anyone please answer my question?

 

[antoniamay]

The key to proper coding is the anatomic area (nasopharynx (92511), nasal (31231) or larynx (31575)) the ENT examines with the scope, it doesn't matter the approach as long as a scope is used and documented. I was told not all the "common areas of focus" had to be documented but it needed to point out the specifics of the main area of exam. 92511 is mainly nasopharynx, everything but the larynx, 31231 is mainly nasal and sinus and then 31575 is the oral and larynx area