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CPT code 31231

  1. Default CPT code 31231
    Medical Coding Books
    I have a provider billing an endoscopy on every office patient even if it is a case of the sniffles. Is this appropriate? Would not a nasal speculum provide the same results? I can see if the condition were not to improve to do this procedure but every single time seems rather excessive.

    Please any advice from the ENT experts I would appreciate!
    Kelly Long CPC, CFE
    Manager Audit and Compliance

  2. Default Excessive.........
    I have worked for ENT for 18 years (12 physicians) and would say yes, nasal endoscopy for every patient is EXCESSIVE, but, on the other hand, as long as the documentation and clinical diagnosis can support the charge.........Have you had any problems with reimbursement? Do you have a good working relationship with this provider? that you might ask why they feel it is necessary for every patient to be scoped. Also, I strongly suggest you advise them that this sort of billing behavior might send up red flags and consequently result in audits and investigations into their billing practices.

    Good Luck...


  3. Default
    I am the auditing investigator.
    Kelly Long CPC, CFE
    Manager Audit and Compliance

  4. #4
    Madison Area Chapter in Madison WI
    Kelly, As a consultant, my first question for each record would be "Is this medical necessary?" If the scope is medical necessary, no problem, I'd say the service is billable.

    If the service isn't medical necessary, I would not support the billing of the scope.
    Happy Coding, Claudia

    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    [email] - website

  5. Default Cpt 31231
    OK, my bad, I was intent on responding I was not paying attention to your credentials
    As Claudia and I both indicated, if the documentation and clinical diagnosis support medical necessity than the service is billable. BUT....and I say this with 18 years and 12 ENT physcians worth of experience, nasal endoscopy is done at the discretion of the physician when nasal speculum exam is not adequate and/or the patient has on ongoing situation and/or post-op care, etc... I am curious, does this physician have an operative note indicating pre/post-op diagnosis, intra-operative findings and indicate anesthesia, etc...for every patient they bill?

    I am inclined to agree with you that this type of billing is excessive...with 12 providers, I have not experienced this........Obviously you are auditing for a reason...

    Good Luck


  6. Smile
    Thank you for the very helpful responses. I have completed my investigation and this particular provider failed to provide the documentation making this procedure medically necessary.

    Have a great weekend!!
    Kelly Long CPC, CFE
    Manager Audit and Compliance

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