Otolaryngology Coding Alert

Watch your ICD-9 codes if the physician performs E/M with removal

Payers may seem notoriously difficult when you-re trying to obtain E/M service payment with impacted cerumen removal--but the ICD-9 codes and modifiers you use can make the difference between denial and deserved dollars.

Otolaryngology coders often wonder whether they can report an E/M service when the physician performs impacted cerumen removal at the same visit. Although circumstances and documentation may justify reporting both the service and the procedure, insurers rarely pay both, so you should know when you can report them together, and when the services are bundled.

Try these five strategies, which can help you recoup payment for performed and documented 99201-99215 (Office or other outpatient visit ...) services in addition to 69210 (Removal impacted cerumen [separate procedure], one or both ears).

Tip 1: Assign Separate Diagnoses

-When looking at the cerumen removal procedure, we must look at what brought the patient to the physician,- says Steven M. Verno, CMBSI, director of reimbursement for Emergency Medical Specialists in Hollywood, Fla. The patient most likely isn't coming in to say, -I-m here to have my cerumen removed.-

Instead, the patient likely presents with complaints of difficulty hearing in one or both ears, possible ear pain associated, and perhaps complaints of a sore throat due to having the eustachian tube involved.

The work involved with examining the patient and determining the appropriate course of action merits two diagnoses: one for the sick visit and the other for impacted cerumen removal.

Otherwise, the insurer will bundle the E/M service into 69210.

Key: The documentation must support both ICD-9 codes. According to most policies, the only appropriate diagnosis to use with 69210 is 380.4 (Impacted cerumen).

The other diagnosis to support the E/M code may represent ear pain (388.7x, Otalgia), otitis media (381-382), or another illness (such as 465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site).

Example: A patient complains of ear pain. Impacted cerumen blocks the eardrum, preventing the otolaryngologist from examining the ear. The physician uses an otoscope and curette to remove the impaction. She then examines the ear and diagnoses the patient with acute purulent otitis media.

In this case, you have two diagnoses--382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum) and 380.4 (Impacted cerumen). You should use the otitis media diagnosis (382.00) for the E/M service, and impacted cerumen (380.4) for the procedure.

The different ICD-9 codes help show the insurer that the physician performed a separate E/M service from the cerumen impaction removal. Be sure that the physician's documentation includes a separately identifiable history, exam and medical decision-making before you report both the E/M and the cerumen removal

Tip 2: Append Modifier 25 to the E/M Service

Another tool that will substantiate 99201-99215 as separate from 69210 is modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), if you append it to the E/M code.

The documentation of the chief complaint, a history of the patient's medical conditions, the examination of more than the ear, and a medical decision to remove the impacted cerumen as well as treatment of the patient's problem can warrant an E/M procedure in addition to the cerumen removal, Verno says. And that means you should append modifier 25 to the E/M code.

Example: When an ENT removes impacted cerumen prior to assessing a patient for otalgia or otitis media, the procedure is not part of the visit, because the physician can't tell what's going on with the ear until she can visualize the eardrum.

Bottom line: The otolaryngologist performs the ear examination to assess the patient's ear-pain complaint and for otitis media. The impacted cerumen removal treats the impaction, which is a separate condition from the potential ear infection.

When you report 69210 and 99201-99215 with different diagnoses, you-ll probably find that most insurers, including United HealthCare and Cigna, want modifier 25 on the E/M service code. Some payers, however, such as Georgia Medicaid, bundle the office visit with the cerumen removal.

Tip 3: Know the Patient's Benefits 
 
NCCI edits state that cerumen removal is not considered inclusive or mutually exclusive with an E/M procedure. However, Verno says, that doesn't mean automatic reimbursement for your practice. -Non-Medicare carriers are not obligated to abide by national NCCI edits,- he says. -They can establish their own edits.- Whether the carrier pays for cerumen removal depends on the patient's plan, he says.

Checkpoint: If possible, ask the patient to bring his benefit manual to his appointment. Verify whether the patient has cerumen removal as a benefit, and make a copy of the manual for your files. Then you-re prepared to provide the carrier with documentation if they deny your claim.

Tip 4: Was It Ear Wash or Cerumen Removal?

Your otolaryngologist documents an ear wash during an E/M service. Do you report both the E/M and 69210? The answer is no. An ear wash does not meet the requirements to report 69210.

How to determine when 69210 applies: According to the July 2005 CPT Assistant, -Removing wax that is not impacted does not warrant the reporting of CPT code 69210.- The AMA states that payment for nonimpacted wax removal is included in the E/M reimbursement.

But CPT Assistant states, -If, however, the wax is truly impacted, then its removal should be reported with 69210 if performed by a physician using at minimum an otoscope and instruments such as wax curettes or, in the case of many otolaryngologists, with an operating microscope and suction plus specific ear instruments (e.g., cup forceps, right angles). Accompanying documentation should indicate the time, effort, and equipment required to provide the service.-

Know Your Carrier's Specifications

Some payers are even stricter than this when writing up their 69210 guidelines. For example, First Coast Service Options, the Medicare payer in Florida, published a bulletin in February 2005 that states that the only reimbursable method of impacted cerumen removal -- is performed by the physician under binocular magnification and generally entails grasping the cerumen plug with forceps, application of suction, and/or extraction with a right-angle hook. In cases of severely impacted ears, injections of local anesthesia may be required.-

Tip 5: Watch Out for Frequency Guidelines

Several Medicare carriers, such as Empire Medicare (a Part B payer in New York and New Jersey), will only reimburse 69210 three to four times per year. But even if your insurer will only reimburse cerumen removal every 90 days, that doesn't mean the ENT can't perform the cerumen removal. It just means you should get an advance beneficiary notice (ABN) from the patient before you perform more frequent cerumen removals.

Potential snag: Because some patients are seeing other physicians (such as an internist) for their cerumen removal services, you can't always be sure that the patient hasn't already fulfilled her 69210 frequency limits within any given 90-day period.

Consider an ABN

Best practice: -Unless you-re sure that no other physician is billing out 69210 to Medicare for that patient, you should use an ABN every time you perform cerumen removal on that patient,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Remember: If the audiologist provides a service on the same date that the otolaryngologist removes the Medicare patient's cerumen impaction, you should report G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing) instead of 69210. This shows the carrier that the physician--not the audiologist--performed the cerumen removal. 

If you do use an ABN, don't forget to append modifier GA (Waiver of liability statement on file) to the procedure code to let the carrier know that the patient signed your practice's ABN.