Reader Question: Cancer Diagnosis Should Be Avoided- Published on Sat, Sep 01, 2001
Question: When our practice bills a triple endoscopy to Medicare, we code each procedure separately with a distinct diagnosis, as follows:
31536 -- laryngoscopy, direct, operative, with biopsy; with operating microscope
161.8 -- malignant neoplasm of contiguous or overlapping sites of larynx whose point of origin cannot be determined
31622 -- bronchoscopy (rigid or flexible); diagnostic, with or without cell washing (separate procedure)
162.9 -- malignant neoplasm of bronchus and lung, unspecified
43200 -- esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
150.3 -- malignant neoplasm, upper third of esophagus.
We don't have problems getting paid for the laryngoscopy and the esophagoscopy, but we always have problems with the bronchoscopy. I am not comfortable using the cancer diagnoses because the pathology report has not yet returned and they may not be definite. But when I use uncertain-behavior codes, the claim is rejected as not medically necessary. The services we are providing are necessary, considering that the bronchoscopy and esophagoscopy are performed to check for metastatic spread. How can I code correctly and get paid for all procedures?
Answer: Without more information, it is difficult to answer this question with any certainty, but some of the ICD-9 coding is incorrect.
There are two issues here: getting paid for all three scoping procedures, and using the correct diagnosis codes.
Although version 7.2 of the national Correct Coding Initiative (CCI) bundles 31535 (a component of 31536) with 31622, the edit has a '"1" indicator, which means it may be bypassed with modifier -59 (distinct procedural service) under certain circumstances, such as, but not limited to, the patient having a separate diagnosis for the laryngoscopy. In this case, however, the carrier has paid for the laryngoscopy but denied the bronchoscopy. Still, it may be worthwhile to append modifier -59 to 31622 to indicate the procedures use different scopes (one scope is removed and the other then inserted) and are being performed for different reasons.
It is inappropriate to use ICD-9 codes that describe malignant neoplasms before the pathology report returns, as this could label the patient incorrectly should the pathology report return negative, even in one location. Also, using "neoplasm of uncertain behavior" codes also is incorrect, because a neoplasm's behavior is deemed uncertain only when the pathology report indicates atypia or dysplasia. Since the report hasn't returned, these codes should not be used.
The correct ICD-9 codes cannot be determined until the pathology report returns. If the claim must be sent in before that, only the appropriate signs and symptoms codes should be used. By using modifier -59 on the bronchoscopy and linking accurate ICD-9 codes to the appropriate procedures, the chances of gaining additional reimbursement increase. If the carrier persists in [...]