Cancer Surveillance

Question:

When a patient comes in for head and neck cancer surveillance with severe xerostomia because of radiation therapy, and the physician does a complete workup for the xerostomia, and there is detailed documentation about the xerostomia, can we bill an E/M service along with the flexible laryngoscopy (31575)?

Answer:

If the patient is seen for follow-up for head and neck cancer and they are also being treated for xerostomia you would be able to report a separate E/M service as long as the workup for the xerostomia is documented and treated or there is a change in plan of care to support the evaluation and management service.

*This response is based on the best information available as of 6/20/24.