ED Coding and Reimbursement Alert

Make sure you are reading the rules for facility rather than office reporting

When your ED doc treats a patient with severe ear pain due to impacted wax, keep in mind that .CPT® 2014 includes a slight but significant change in the code descriptor for 69210 (Removal of impacted cerumen requiring instrumentation, unilateral). Previously the code read, “Removal impacted cerumen (separate procedure), 1 or both ears.” The new code descriptor makes it clear that to report a bilateral procedure the modifier 50 should be appended.

Clear Your Ears To Be Sure You Hear This Distinction

The AMA RBRVS Update Committee (RUC) revalued the service with a resultant change in Medicare payment policy. The payment 69210 in the office setting will drop from $53.08 to $43.26; however, that is not true in the facility setting including the ED.

ED heads up: In the facility setting, there is a slight increase in the 2014 Medicare payment from $ 32.66 to $34.03. The work RVU remains the same at 0.61, as it has been for 20 years. The difference in total RVUs for the office as opposed to the ED payment rates is due to the decrease in practice expense valuation for 2014 in the office setting, says Mike Granovsky, MD, CPC, FACEP, President of LogixHealth, an ED coding and billing company in Bedford, MA.

What About Modifier -50?

The biggest impact of the change is that when you remove impacted cerumen from both ears during a single encounter, you now need to use modifier 50 (Bilateral procedure) to indicate that both ears were done. CPT® 2014 specifically instructs to report bilateral procedures with modifier 50, says Granovsky.

However, in its Final Rule comments, CMS stated they feel the physiologic processes that create cerumen impaction likely will affect both ears. Therefore, they will only allow one unit of CPT® 69210 to be billed when furnished bilaterally. The AMA has protested this ruling from CMS and asked for clarification on the basis of this policy decision. Private payers may adopt this policy as well, so check on your local payer policy, he adds.

Check CCI Before Giving Up On Billing 69210 And An E/M Service

Another area in which facility and non-facility venues differ on payment policy is with the to Correct Coding Initiative (CCI) edits for 69210. According to the CCI edits, 69210 is bundled into an E/M service done on the same date of service for the office or other outpatient codes; however, that is not true with the ED E/M codes 99281-99285.

For the Medicare population, removal of impacted cerumen is a service commonly done when the patient presents for management of chronic conditions or for an unrelated sick visit, so it is often appropriate to report a separately billable E/M service in the ED setting, warns Granovsky.

Dr. Granovsky offers this ED clinical example to demonstrate when a separately identifiable E/M code is appropriate.

A patient presents to the ED complaining of pain and pressure in his right ear which is worse when swallowing. During an expanded problem focused history and examination, the physician discovers cerumen impacted in the right ear and notes indicate that the eardrums cannot be visualized. The physician uses a curette to remove the impacted cerumen, after which he can see the ear drum is red and distended. The final diagnosis is otitis media immediately improves the patient’s hearing and removes the discomfort.

On the claim, you would report the following:

• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the E/M service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and cerumen removal were separate services
• 69210 for the cerumen removal
  
• 382.9 (Unspecified otitis media) to 99282 to represent the patient’s otitis media
  
• 380.4 (Impacted cerumen) appended to 69210 to represent the patient’s cerumen impaction
  

Under ICD-10, those codes would be H66.90 (Otitis media, unspecified ear) and H61.21 (Impacted cerumen, right ear). The final digit will determine unspecified, right, left or bilateral.