August 2008: Coding - It's All in the Details

Michael Setzen, MD
Chair, Patient Advocacy Committee

At the most recent American Rhinologic Society Spring meeting at COSM 2008, I was asked to give a presentation to residents and fellows on Coding.

I discussed in detail the need to document what you do, why you do it, and how you do it.

This kind of documentation is important because not only does it assist insurance carriers with respect to appropriate reimbursement for services rendered, but it also will assist you in both an audit and or litigation. If it is not documented in the chart, it did not happen.

The three most important elements are documentation, the need to show medical necessity, and the ability to code accurately.

It no longer suffices to say "nasal endoscopy was carried out", but more importantly one must document exactly why you did it, how you did it, and what you saw. One must document the presence of middle and inferior turbinate abnormalities, ostiomeatal complex abnormalities, septal abnormalities, and the presence of discharge from the ostiomeatal complex, be it clear fluid or colored fluid. The presence of nasal polyps must be documented.

Coding not only relates to the procedural codes, namely CPT codes, but furthermore to the diagnosis codes or the ICD-9 codes. To be reimbursed appropriately, one must correctly match the ICD-9 code with the correct CPT code.

Modifiers inform the insurance company of what you did. Modifier 50 lets the insurance company know that this was a bilateral procedure. Modifier 79 indicates that a procedure was done during the global period of another procedure. Modifier 51 indicates that a secondary procedure was done over and above the primary procedure. Modifiers 22 and 52 can be used, but these codes generate a tremendous amount of paperwork. Modifier 52 informs the carrier that the procedure performed was less than the true CPT code, while modifier 22 indicates that the procedure was more extensive than the usual CPT code. Modifier 22 can be used for revision endoscopic sinus surgery which has the same CPT codes as a primary or initial endoscopic sinus surgery procedure.

A recent change in CPT coding relates to the fact that in rare situations one can code for both fiberoptic nasal endoscopy and fiberoptic laryngoscopy, when two separate scopes are used for two different diagnoses. For example, if one were to perform true rigid nasal endoscopy for frontal sinusitis and then flexible fiberoptic laryngoscopy to document the presence of laryngopharyngitis, then two CPT codes are warranted. One must realize that it is possible to use the flexible scope alone to diagnose both nasal and laryngeal problems, and therefore the use of one scope, namely a flexible fiberoptic scope can be used. One must caution the membership that the use of these two codes together should be an extremely rare phenomenon, only in the extreme situation. Excessive use these two codes together will raise a red flag and one will be audited and this will hurt the reimbursement of both of these CPT codes. With this in mind, one must be warned that the use of these two CPT codes together should be used rarely.

Reprinted with permission ENToday June 2008 Vol.3 No.6 Page 1

Return to the Patient Advocacy Homepage.

Revised 8/2008
©American Rhinologic Society