Facing Diagnostic Endoscopy Denials? Here’s Help from an ENT Coding & Billing Expert

Reimbursement denials are frustrating, but you can take some simple documentation steps to prevent them from bringing your revenue cycle management process to a grinding halt.

Denials often happen because clinicians and payers approach clinical documentation very differently.

For doctors performing diagnostic endoscopies–CPT® codes 31231 or 31575, for example– it seems very logical to note only abnormal findings. That’s because clinicians use documentation to remind themselves or inform their peers about what’s going on with the patient. It doesn’t make sense to them to document what the diagnostic procedure has revealed to be normal. Clinicians simply understand that anything not mentioned in the note is normal and therefore not relevant. Besides, there’s no need to take further clinical action on normal findings, so why put it in the note?

Payers, however, view clinical documentation much differently. They want providers to follow Clinical Documentation Improvement (CDI) guidelines. When payers look at a procedure note during payment processing or during an audit, they want to see both abnormal and normal findings in the diagnostic endoscopy note. If they don’t see a record of both in the note, they can’t confirm proof that the doctor performed all of the procedure, which causes understandable compliance challenges. For that reason, payers will often deny the claim or flag the payment during an audit.

Example: How To Document Normal & Abnormal Findings for CPT® code 31231

To illustrate how CDI requires clinicians to document both normal and abnormal findings, let’s take a look at CPT® code 31231 Nasal endoscopy, diagnostic, unilateral, or bilateral (separate procedure). 

(Because 31231 can be either unilateral or bilateral, there is no modifier needed if performed only on one side.)

The CPT guidelines for this code indicate that clinicians should document both abnormal and normal findings for each of these areas: 

• • Interior nasal cavity
  • Middle meatus
  • Superior meatus
  • Turbinates
  • Spheno-ethmoid recess

If the clinician doesn’t view all of these areas because they are not clinically relevant, they should note that in the documentation. They should also note any anatomy that’s missing as a result of previous surgeries. 

How To Make CDI Guidelines Easier for Clinicians To Follow

Clinicians often view CDI guidelines as unnecessarily bureaucratic, and they’re not wrong about that. But because the payers hold the reimbursement that providers seek, compliance demands providers play by their rules.

The coders and billers in your organization can help by creating templates. (Spoiler alert: They may have already created templates that clinicians aren’t paying much attention to.)

Your EHR could list each area the clinician must document in order to ensure that claims are clean. Or, if your physicians are still using dictation, paper documentation, or some combination of the two, your CDI team can create forms that remind clinicians what they must document for each code to ensure compliant claims that garner well-deserved reimbursement and pass even the most rigorous audits.