Medical Coding Resource - Ask How Far the Scope Went

While reviewing the physician's notes, how should you count exam elements when they are obtained through a scope such as 31231 or 31575? Do those elements support the E/M and the scope or just one or the other? You always thought the elements collected via the scope support the procedure only.

If you're reporting an evaluation & management service 99201-99215, Office or other outpatient visit...) with modifier 25 (Significant, separately identifiable Evaluation & Management service by the same physician on the same day of the procedure or other service) and reporting the scope separately, don't include the endoscopy finding in the exam section of the E/M service. The evaluation & management service must be separately identifiable from the scope procedure.

When the ENT uses the same flexible scope to view the nasal passages, nasopharynx and/or the larynx, making the right code choice is tough. The standard answer is that you code the scope that goes the farthest (since you have to pass the other organs on the way) and what scope is dictated based on the diagnosis medical necessity.

For instance, if the ENT examines the larynx with a flexible scope, the proper code is 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) even if the examiner inspected the nasal cavity and nasopharynx on the way down. If the examiner finds a problem further down than he had initially planned to examine, rethink the code choice. For example, if the ENT intends to carry out a nasal endoscopy (31231, Nasal endoscopy,diagnostic, unilateral or bilateral [separate procedure]) and then sees a nasopharyngeal mass that prompts him to pass the scope to the nasopharynx, 92511(Nasopharyngoscopy with endoscope [separate procedure]) is the right code.

To end with, look at the patient's chief complaint and why the ENT chose to do an endoscopy. The diagnosis must assist the procedure. For instance, if the patient has chronic sinusitis, 31231 would be right; if the patient has suspected postnasal drip, 31575 would be proper.

Remember: ENTs often get caught up trying to code 31575 when they are checking the terminal end of the tubes in the nasopharynx. If the diagnosis is eustachian tube dysfunction (381.81), there's no necessity to examine all the way to the larynx. Stopping at the nasopharynx, (92511) is what supports this diagnosis, and sometimes that is even met with a denial and requires appeal.

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