# Medicare Guidelines CPT 69209



## ivygirl18@hotmail.com

Hello,

I am trying to find the Medicare guidelines/regulations regarding the ear lavage CPT 69209. I need to find documentation the provider can bill this even if the staff performs this. Please help!!

I have found articles on AAPC website but cant find anything from Medicare!


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## michellepilcher

Every thing I find indicates 'physician skill' when billing for cerumen removal.  Anything less than that is not covered.

Indications:

The following applies to all payable cerumen disimpaction, CPT 69210 and HCPCS code G0268

Medically necessary removal of impacted cerumen requires a physician's skill when removal by an individual other than a physician or qualified non-physician practitioner poses an unacceptable risk of complications such as tympanic membrane perforation.

Cerumen removal requiring a physician’s skill may include cases where the tympanic membrane cannot be observed (e.g., total occlusion or impaction), there are overt medical contraindications such as anatomical abnormalities, surgical modifications, or risk of infection, presence of medical conditions that pose undue risk of excessive bleeding (e.g., use of anticoagulants), or the cerumen cannot be removed safely without undue risk of abrasion, laceration, or tympanic membrane perforation.

Removal of impacted cerumen is covered if it is reasonable and necessary for the diagnosis or treatment of illness or injury.
*
Payment is made for impacted cerumen removal requiring a physician's skill when personally performed by a physician.*

Payment may be made only for: a) medically necessary removal of symptomatic impacted cerumen; b) medically necessary removal of impacted cerumen impeding the physician's ability to properly evaluate or manage other signs, symptoms or conditions (e.g., examination of the tympanic membrane in cases of otitis media); or c) medically necessary removal of impacted cerumen impeding a physician's or audiologist's ability to perform covered, medically necessary audiometry.

Payment may be made for both removal of impacted cerumen and an E/M service only if the E/M service represents a medically necessary, significant and separately identifiable service that is supported by medical record documentation.

Payment for G0268 may be made to a physician whose skill is required to remove impacted cerumen on the same date as his or her employed audiologist performs audiologic function testing.

Limitations:
*
Billing and reimbursement for CPT code 69210 or HCPCS code G0268 is limited to clinical circumstances where documentation supports these to be reasonable and necessary services requiring a physician's skill. The routine removal of asymptomatic, non-impacted, non-obstructive cerumen does not generally require a physician's skill and is thus not considered reasonable and necessary.*

Visualization aids, such as, but not necessarily limited to binocular microscopy, are considered to be included in the reimbursement for CPT code 69210 and HCPCS code G0268 and should not be billed separately.

When the sole reason for the visit is the medically necessary removal of symptomatic impacted cerumen, an E&M service may not also be billed in addition.

An E&M service on the same day as removal of impacted cerumen may not be billed unless it represents and is documented to be a significant, separately identifiable service on the same day.
For example:

    If the patient has pain in the external ear as his/her only complaint and the removal of cerumen addresses that complaint, one should bill only for removal of the cerumen, CPT code 69210.
    If the patient also has symptoms of otitis media requiring further evaluation, then it may be justified to also bill for an E&M service with modifier –25.

HCPCS code G0268 should be billed only where a physician's skill is needed to remove impacted cerumen on the same day as audiologic function testing performed by his/her employed audiologist. This code should not be used when the audiologist removes the cerumen, because removal of cerumen is considered to be part of the diagnostic testing and is not paid separately.

It is recognized that audiologists' education, experience or practice may include or require techniques of cerumen removal. However, Medicare can pay audiologists only for medically necessary diagnostic testing, which is considered to include any incidental cerumen removal by the audiologist. Medicare cannot reimburse audiologists for CPT code 69210 or HCPCS code G0268 under any circumstances.

This was from an LCD for CGS Administrators (which was the only LCD I could find)

Hope that helps.


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## thomas7331

69210 requires physician skill, but 69209 does not.  If you look up the code in the Medicare Physician Fee Schedule, 69209 is assigned a PCTC indicator of '5' which is defined as an "incident to code" which falls into the same category as codes such as administration of immunizations or infusions:  _"This indicator identifies codes that describe services covered incident to a physician's service when they are provided by auxiliary personnel employed by the physician and working under his or her direct personal supervision. Payment may not be made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient department."_  In the office setting and when performed by staff, 69209 can be billed by the physician when the 'incident to' requirements are met.


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