In some cancer or trauma patients, otolaryngologists may perform three endoscopic procedures laryngoscopy, bronchoscopy and esophagoscopy using three different kinds of scopes, collectively referred to as a panendoscopy, or a triple endoscopy. Although panendoscopies are considered standard medical practice in certain situations involving such patients, the national Correct Coding Initiative (CCI) bundles the laryngoscopy (31535, laryngoscopy, direct, operative, with biopsy) to the bronchoscopy (31622, bronchoscopy, [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]).
Both procedures may be billable as long as there is a separate diagnosis for each of the two scopes; and modifier -59 (distinct procedural service) is attached to the laryngoscopy. The esophagoscopy (43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) is not bundled to either of the other two scopes and usually is payable separately.
Why Panendoscopies Are Performed
A panendoscopy typically is performed on patients with a suspected carcinoma or on laryngeal trauma patients. For example, the otolaryngologist may feel an unusual mass while examining the patient and schedule a direct laryngoscopy with biopsy.
After taking the biopsy of the laryngeal carcinoma, the otolaryngologist removes the laryngoscope and inserts a bronchoscope to make sure the pathology hasnt spread to the nearby bronchi. The esophagoscopy is performed for similar reasons because all three scopes visually inspect adjacent anatomic areas.
Patients with laryngeal injury, a less frequent occurrence, also may require panendoscopy. Such injuries may result from gunshot or knife wounds, as well as automobile or other accidents, and can involve either blunt or penetrating trauma, resulting in a crushed larynx, cartilage fracture or soft tissue injuries. Although severe injuries usually have obvious findings, less severe but equally important injuries may present with more subtle signs and symptoms.
For example, hoarseness or a change in the patients voice should alert the physician to the possibility of laryngeal injury. Other symptoms include dysphagia (787.2) and anterior neck pain (723.1). If the patients airway is stable, the otolaryngologist may need to use all three panendoscopy scopes to assess correctly the depth of the patients injuries.
Although many otolaryngologists were trained to perform panendoscopies in such situations, Medicares CCI bundles 31535 as a component of 31622. This edit is unusual; in that a laryngoscopy with biopsy normally would not be considered a component of a bronchoscopy; and because the CCI offers no explanation for its edits, some coding specialists speculate that Medicare believes the scoping function of the laryngoscopy may be performed by the bronchoscopy. There are, however, two problems with this line [...]