NCCI Edits: Watch Out For These Endoscopy Bundles

Code 31575 includes 92511 and 31231 except under these conditions.

Singling out the correct endoscopy code when your otolaryngologist examines multiple areas in the sinuses and throat isn’t always easy, but in most cases it’s imperative to settle on one, according to National Correct Coding Initiative (CCI) edits. You can adhere to these edits and avoid payback requests if you stick to these guidelines.

3 Rules Guide the Way

Rule #1: Never report 92511 (Nasopharyngoscopy with endoscope[separate procedure]) and 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) together, says Stephen R. Levinson, MD, otolaryngologist and coding consultant based in Easton, Conn. Code 92511 is a component of Column 1 code 31231. The bundle has a modifier indicator of “0” — thus, no modifier can break this bundle.

Rule #2: Code 92511 is a component of Column 1 code 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) but a modifier is allowed in order to differentiate between the services provided (that is, you may append modifier 59 [Distinct procedural services] if there are separate and identifiable services with separate medical indications). Report 92511 in conjunction with 31575 for the same encounter, says Levinson, only if the following conditions are met:

there are separate medical indications for examining each area (for instance, 784.49 for hoarseness with 31575 in an adult patient with a hyperactive gag reflex and 381.4 for a unilateral or bilateral middle ear effusion with 92511, which would be a rare occurrence), and
the ENT uses a different scope for each, separate procedure because there is a documented reason that the fiberoptic scope did not provide adequate visualization of the nasopharynx. “This would be highly unlikely,” emphasizes Levinson.

Rule #3: Code 31231 is a component of Column 1 code 31575 but a modifier is allowed in order...

Code 31575 includes 92511 and 31231 except under these conditions.

there are separate medical indications for examining each area (for instance, 784.49 for hoarseness with 31575 in an adult patient with a hyperactive gag reflex and 381.4 for a unilateral or bilateral middle ear effusion with 92511, which would be a rare occurrence), and
the ENT uses a different scope for each, separate procedure because there is a documented reason that the fiberoptic scope did not provide adequate visualization of the nasopharynx. “This would be highly unlikely,” emphasizes Levinson.

Rule #3: Code 31231 is a component of Column 1 code 31575 but a modifier is allowed in order to differentiate between the services provided. The need to coreport these services for the same encounter, however, would also occur very infrequently. The combination of 31575 with 31231 would similarly call for separate, sufficient medical indications and the medically indicated use of separate endoscopes, says Levinson.

Think Before Appending 59

Some coders mistakenly think that appending modifier 59 to an endoscopy bundle will result in dual payment when the ENT visualizes more than one area. Using 59, however, is incorrect in most instances.

When CCI created the endoscopy bundles, it realized that the bundled codes described different sites, points out Barbara J. Cobuzzi, MBA, CPC, CPCH, CPC-P, CENTC, CHCC, president of N.J.-based CRN Healthcare Solutions. So attempting to break the endoscopy bundle based on the ENT examining two different sites is not appropriate.

Exception: If the ENT performed the two endoscopies at two different encounters on the same day for two distinct medical reasons, you would be safe in reporting 59, explains Cobuzzi. This scenario would be uncommon.

Example: If the ENT performed a laryngoscopy (31575) in the office in the morning for postnasal drip (784.91), and in the afternoon she performed a nasal endoscopy (31231) for unrelated epistaxis (784.7), you may append 59 to the column 2 code 31231.

@ Otolaryngology Coding Alert. Editor: Stacie Borrello, MA