Question

The pulmonologist in a multispecialty group refers a patient to the otolaryngologist 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 rep

Answer 1

The codes involved for this case are: Current Procedural Terminology (CPT) 99395, and the code for the ICD-10-CM diagnoses are J37-B95, J37-B97, which according to the coding manual refer to chronic laryngitis / tracheitis .