Don't have a TCI SuperCoder account yet? Become a Member >>

Otolaryngology Coding Alert

Clip and Save:

Spot This Documentation to Confidently Report 31575

These reasons and indications clue you in that scope is medically necessary

Not sure if you should code that scope? Look for these details that give credence to billing 31575. Show Why Mirror Exam Didn't Work If a payer bundles laryngoscopy into a same-day E/M service, documentation that shows why a mirror exam (included in the E/M service) was insufficient will help you overturn the EOB determination.

Educate your ENTs on the importance of including this information, presented by Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. Medically necessary reasons that support performing 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) include but are not limited to:

- macroglossia preventing mirror examination
- gag reflex preventing mirror examination
- trismus preventing mirror examination
- patient unable to cooperate to allow mirror examination due to age (such as infants) or mental condition (mental retardation, dementia, etc.)
- hoarseness, dysphasia, aspiration not clearly evaluated by indirect laryngoscopy
- lesion identified by mirror examination needing further evaluation
- anterior commissure not completely visualized by mirror examination
- aspiration suspected that cannot be evaluated by mirror examination
- evaluation of the larynx and immediate subglottis in patients for tracheal decannulation
- acute airway obstruction evaluation. Remember: Using a mirror (31505, Laryngoscopy, indirect; diagnostic [separate procedure]) to perform an exam of the throat, oropharynx, etc., is part of the E/M service, based on the 1997 E/M guidelines, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. Check if Preprocedure Dx Indicates 31575  Medical policies differ regarding diagnoses that support performing 31575. But some indications for 31575 may be:

- airway obstruction (chronic, 496; NEC, 519.8)
- aspiration, chronic (507.0, Pneumonitis due to inhalation of food or vomitus)
- cough, chronic (786.2)
- dysphagia (787.2x [requires 5th digit as of Oct. 1, 2007])
- dyspnea (786.09)
- foreign body (933.1, larynx)
- head and neck mass, no primary (784.2)
- hemoptysis (786.3)
- history of tobacco use (V15.82)
- hoarseness, chronic (784.49)
- laryngeal trauma (959.09)
- neoplasm, suspected
- obstructive sleep apnea (OSA) severe snoring (327.23)
- otalgia (388.70)
- stridor (786.1)
- throat pain (784.1). You may use the ICD-9 code associated with the indication for the E/M service (such as 99201-99215, Office or other outpatient visit -) and, when available, link the definitive diagnosis to the scope (31575) to help show medical necessity.

Example: An established patient presents complaining of hoarseness (784.49). The otolaryngologist performs and documents a history, exam and medical decision-making. Based on his findings, he decides a laryngoscopy is necessary and separately documents the procedure. The scope reveals a polyp (478.4, Polyp of vocal cord or larynx).

Because the otolaryngologist performed a separate history, exam and medical decision-making from that included in the laryngoscopy, the visit meets modifier 25's definition [...]