Office Visit & Procedure on Same Day – Using Modifier 25

Question:

We frequently do a flexible laryngoscopy (31575) or nasal endoscopy (31231) when we see a patient. We always bill the office visit code with modifier 25. Lately, we seem to be getting more denials and have to send in our note for justification. We don’t always get paid. Can you shed any light on this issue?

Answer:

Good question and our clients are telling us they are also seeing more denials for modifier 25. The answer is long and complicated which is why Kim is doing a webinar on proper use of modifier 25 on March 23, 2022. In general, frequently it is appropriate to report both an E/M code and the minor procedure on the same day for new patients. However, for established patients where you’re evaluating them for the same problem and you do the procedure it may only be appropriate to report the procedure code if you are not changing the plan of care or doing any additional medical decision making.

Be sure to sign up for Kim’s modifier 25 webinar here:https://karenzupko.com/using-modifier-25-in-otolaryngology-rewards-and-ramifications/. And, remember, the 2nd edition of Kim’s ENT coding book was recently published – you can order it here and get the KZA discount:https://karenzupko.com/the-essential-guide/.

*This response is based on the best information available as of 03/10/22.

Nasal Wall Reconstruction

Question:

One of our physicians is scheduling a nasal wall reconstruction with Latera®.  He is wanting to use code 30465 (repair nasal vestibular stenosis).  I know there is a code for Latera which is 30468 and I feel we should use this code.  Please give me your opinion.

Answer:

CPT 30468 was created specifically for procedures such as the Latera implant. It is absolutely incorrect to use 30465 for this procedure.

*This response is based on the best information available as of 02/24/22.

Postop Endoscopic Sinus Debridements

Question:

If one of our physicians performed a septoplasty and sinus surgery and then the patient comes in the office for a 31237 (endoscopic sinus debridement), would we use a modifier 79 (unrelated procedure in a global period) or 58 (staged/anticipated procedure in a global)?

Answer:

You’ll use modifier 79. The debridements are unrelated (modifier 79) to the procedure for which you are in a global period (septoplasty, 30520, 90 day global period).

*This response is based on the best information available as of 02/10/22.

Why this NCCI Edit?

Question:

In the office, one of our physicians, performed 31296-50 (endoscopic dilation frontal sinus), 31295-50 (endoscopic dilation maxillary sinus) and 69706 (endoscopic eustachian tube dilation). The insurance is paying on the 31296 and 31295 but will not pay on the 69706 because Medicare considers it unbundled. Why is the ear procedure is considered bundled?

Answer:

Yes, this is a problem. For some reason, Medicare’s National Correct Coding Initiative (NCCI) edits bundle the new eustachian tube dilation codes with endoscopic sinus codes, and other procedures like a direct laryngoscopy and bronchoscopy. It is not clear to us why NCCI would bundle these very separate procedures. Not only that, but most of the edits do not allow a modifier to override it.

Anyone can express concerns about NCCI edits and request a change. Here is the NCCI Contractor contact information:

National Correct Coding Initiative Contractor
Email:NCCIPTPMUE@cms.hhs.gov
P.O. Box 368
Pittsboro, IN 46167

Fax #: 317-571-1745

Refer to the CMS website for more information about NCCI edits:https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd

*This response is based on the best information available as of 01/27/22.

Bronchoscopy with Direct Laryngoscopy

Question:

I’m trying to figure out when I can bill for both a direct laryngoscopy and a bronchoscopy.  It seems very confusing so I would appreciate it if you could help.

Answer:

Sure!  CPT 31622 (diagnostic bronchoscopy) may be separately reported when both of these criteria are met: 1) a separate piece of equipment, other than that used for the direct laryngoscopy, is used, and 2) the scope entered the right and/or left bronchus. If neither criteria is met, then 31622 is not separately reported.  It goes without saying that you must have established medical necessity for the procedure (e.g., diagnosis statements, Indications paragraph).

*This response is based on the best information available as of 8/19/21.

Does Type of Scope – Rigid or Flexible – Matter for Coding?

Question:

Does 31231 (nasal endoscopy) have to be done with a rigid scope?

Answer:

The CPT descriptor for 31231 is: Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure). Notice it does not specify whether the scope must be rigid or flexible. That said, CPT makes it clear that the anatomic structures examined in 31231 include the interior of the nasal cavity and the middle and superior meatus, the turbinates, and the sphenoethmoid recess.

Question:

Does 92511 (nasopharyngoscopy) require use of a flexible scope?

Answer:

CPT does not specify what type of scope is used for 92511 (Nasopharyngoscopy with endoscope (separate procedure)).  You could use a rigid or flexible scope.  The most important aspect of 92511 is the anatomic structure(s) examined which would include the nasal cavity, nasopharynx (e.g., adenoids) and Eustachian tube openings.

Question:

Does 31575 (laryngoscopy) require the use of a flexible scope?

Answer:

Yes. The CPT descriptor is “Laryngoscopy, flexible; diagnostic.”  Notice the word “flexible” is in the code language.

*This response is based on the best information available as of 05/27/21.