You Be the Coder: Understand How to Count Exam Element Obtained Through a Scope

Why This Topic Matters

Accurate handling of scope-obtained findings affects both procedure reporting and E/M selection, and it can influence whether documentation supports separate reporting, denials, or appeal considerations.

Article Sections

1. Question

   A reader asks how to count examination elements obtained during scope procedures and whether those findings support the procedure, the E/M service, or both.

2. Answer

   The response addresses E/M reporting with modifier 25, documentation separation between the visit and the scope, and general scope-selection considerations for ENT endoscopy based on the extent of the exam and medical necessity.

3. Note

   A closing note discusses a common ENT documentation issue involving evaluation of the nasopharynx, diagnosis support, and the possibility of claim denial or appeal.