SAN DIEGO-In order to remain compliant, as well as to receive fair and appropriate reimbursement, you must code and document correctly, said Michael Setzen, MD, Clinical Associate Professor of Otolaryngology at NYU School of Medicine and Senior Clinical Attending in Otolaryngology at North Shore University Hospital in New York, when he moderated the panel discussion, How the Experts Code and Document Laryngology and Esophagology in the Office and the OR, at the April 2007 Combined Otolaryngology Spring Meeting.
Explore this issue:August 2007
Furthermore, you must show medical necessity and use correct CPT codes that match the congruous ICD-9 codes, continued Dr. Setzen. Otolaryngologists need to understand that proper coding is not only necessary for reimbursement, but that it will also assist them in the validity of their claim, should they ever be audited.
As he showed a slide of a jail cell versus a stack of money, panelist Clark Rosen, MD, Director of the University of Pittsburgh Voice Center and Associate Professor of Otolaryngology at the University of Pittsburgh School of Medicine, stated, This image is what should guide you, not paying off your car or overhead. You must code in an ethical and appropriate fashion to avoid having someone come and knock on your door asking for a payback.
Which is exactly what happened to some otolaryngologists who incorrectly billed E&M services-that is, evaluation and management-using a -25 modifier with laryngoscopies, said panelist Barbara Cobuzzi, MBA, Director of Outreach Programs for the American Academy of Professional Coders. Those who didn’t have the supporting documentation which showed that the E&M service was a ‘significant and separately identifiable’ service from the laryngoscopy [the definition of the -25 modifier] to dispute the refund request had to send in refunds.
The key with the -25 modifier is that any minor procedure, such as a laryngoscopy, includes minor history exam and medical decision making [MDM] in the procedure already, continued Ms. Cobuzzi. You have to make sure that the documentation shows that the E&M was beyond the included minor E&M service. The E&M service must be medically necessary, as well as significantly and separately identifiable from the laryngoscopy procedure. It can’t be part of your otolaryngology exam; you can’t double-dip. (See sidebar.)
However, if you decide to do the laryngoscopy because of inadequate visualization and you document this problem in your chart, then you can take credit for it in the exam, as well as for the procedure, explained Ms. Cobuzzi.