Question

The pulmonologist in a multispecialty group refers a patient to the otolaryngologist in the same group, same tax ID, because he thinks that the shortness of breath that the patient is experiencing may be due to sinusitis and laryngopharyngeal reflux (LPR). The otolaryngologist decides to perform a rigid bilateral nasal endoscopy to get a better look at what is going on in the sinuses and a flexible laryngoscopy to determine if (LPR) is contributing to the problems because he could not get adequate visualization on manual exam. First the bilateral nasal endoscopy is performed and the otolaryngologist diagnosis chronic pansinusitis. Next a flexible fiberoptic laryngoscope is introduced nasally and the larynx and trachea are inspected. The diagnosis is chronic laryngitis/tracheitis and LPR. He prescribes Singulair and Nexium and proposes endoscopic surgery will be considered in the future if the current treatment does not fully take care of the problems experienced by the patient. What CPT® and ICD-10-CM codes are reported for the procedure?

Answer 1

The CPT® and ICD-10-CM codes that are reported for the procedure are 31575, 31231-59, J32.4 and J37.1 because the nasal endoscopy and laryngoscopy can be both performed via the nasal cavity.

The code 31575 is for Laryngoscopy/Fiberoptic/Diagnostic code. Next, CPT code 31231-59 describes a unilateral or bilateral procedure with modifier 59 is appended.

Moreover, in the Index to Diseases and Injuries, look for pansinusitis (chronic) and it will direct you to J32.4, which the doctor diagnose the patient of chronic pansinusitis and the code J37.1 is for laryngotracheitis/chronic that encompasses the LPR and the chronic laryngitis and tracheitis.