Otolaryngology Coding Alert

Coding for cerumen removal involves varying strategies depending on the scenario. Removing earwax (cerumen) is among the smallest-value services that otolaryngologists provide, yet because it is done frequently and can be time consuming, practices are losing out financially.

There are three main scenarios when the otolaryngologist will remove cerumen, says Kim Pollock, RN, MBA, an otolaryngology coding and reimbursement specialist in Dallas, TX:

1. Earwax removal in conjunction with a hearing test, or audiogram;

2. Cerumen removal alone with the use of a scope (Sometimes a primary-care physician will remove cerumen simply by washing out the ear, but if the impacted
cerumen requires intervention by an otolaryngologist, the scope is likely to be used.);

3. Cerumen removal during an examination.
According to Pollock, who conducts coding seminars for Karen Zupko and Associates, a Chicago, IL-based physician practice management consulting firm, each of these three scenarios involves different coding strategies.

1. Same day as hearing test. There is nothing in CPT 1999 that prohibits otolaryngologists from billing cerumen removal (69210, removal of impacted cerumen [separate procedure], one or both ears) on the same day as an audiogram (92557, comprehensive audiometry threshold evaluation and speech recognition), Pollock says. However, Medicare will not pay for the two together. According to the National Correct Coding Initiative (NCCI), cerumen removal is bundled into the hearing test, says Gretchen Segado, CPC, assistant compliance officer at Jefferson University in Philadelphia, PA, despite the fact that removing earwax can take as long as half an hour using sophisticated equipment. Medicare says a hearing test cannot be performed if the patients ears are full of wax. Therefore, Medicare considers the cerumen removal a necessary component of the hearing test if the patient requires it.

Still, Pollock advises her clients to report both procedures. Even though Medicare wont pay for the cerumen removal separately, many private carriers will. When Medicare denies the 69210 on the explanation of benefits (EOB), she recommends adjusting that charge off to a disallowed adjustment code and posting the payment for the audiogram.

2. Office scope cant be billed. In most cases, otolaryngologists will use a scope for removing earwax. However, whether the scope is used or not, the only procedure that may be billed is the cerumen removalcode 69210.

Billing for 92504 (binocular microscopy [separate diagnostic procedure]) is not appropriate, because 92504 is a separate procedure.

Note: Although the 92504 has fewer RVUs (0.6) than removal of cerumen, these are valued into code 69210, so 92504 cannot be billed separately.

This may frustrate some otolaryngologists because removal of cerumen can be a difficult, time-consuming and delicate procedure.

But Pollock says that if physicians were to bill for all incidences of cerumen removal, the more difficult cases would be offset by the routine incidences.

CPT code 69990 (operating microscope) should never be billed for cerumen removal, Pollock says, because it is an add-on procedure code for surgical codes. She points to Medicares proposed guidelines for 2000, which state that 69990 may be billed only for certain neurosurgical codes, which used to be billed with a now-deleted code61712. Pollock says, Otolaryngologists should never use 69990 as an add-on procedure code where the primary procedure has fewer relative value units (RVUs) than the 69990. Cerumen removal is valued at 1.06 RVUs, while 69990 has 6.02. Since the 69990 is reimbursed at nearly six times the rate of the cerumen removal, billing for it would raise a red flag and is clearly inappropriate.

3. E/M visit requires separate diagnosis code. When billing the 69210 on its own, the correct corresponding diagnosis code is 380.4 (impacted cerumen). However, if the physician uses 380.4 for both the removal of the wax and the E/M code, the exam likely will be denied because, according to Pollock, this diagnosis code only justifies removing the wax,
not the exam.

For example, during an initial visit or consultation, the otolaryngologist diagnoses the patient with cerumen impaction. If the intent of the visit or encounter is for cerumen removal, and typically the documentation only supports cerumen removal, then that is the only code that should be billed, Pollock says. Even though the otolaryngologist may dispute this, citing the fact that he or she did a comprehensive history and exam, Pollock says, the medical decision-making constitutes a diagnosis of impacted cerumen, and payers have a hard time justifying E/M codes for that diagnosis. In addition, the diagnosis does not demonstrate the medical necessity of a comprehensive history and exam, and although E/M codes are supported by the level of history, exam and medical decision-making, that work must be medically necessary.

Adding to the difficulty is the minimal nature of the documentation typically provided by otolaryngologists to justify an E/M in such situations, Pollock says, often consisting of notes stating little more than that the patient was referred by an internist, had wax in his ears, the wax was removed, and the patient is to return PRN (as needed). Such documentation, Pollock says, does not substantiate billing both for E/M services and cerumen removal.

Since they cannot bill both for the wax removal and the E/M, some otolaryngologists may wish to charge for the E/M and drop the cerumen removal if the level of E/M they provide reimburses at a higher level of RVUs. However, this approach will likely be rejected by the payer and could result in an audit, because the diagnosis (impacted cerumen) will not match the E/M service billed.

On the other hand, if the otolaryngologist is seeing a new patient with impacted cerumen and he or she performs an E/M service due to some other problem, such as a neck mass or ringing in the ears, the second diagnosis code will justify the E/M service billed. Of course, a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) must be attached to the E/M code.

Note: If the otolaryngologist removes cerumen from an established patient who comes in regularly just to have his ears cleaned, only 69210 may be billed.

Sometimes, all three cerumen removal scenarios occur during the same session. A patient is diagnosed with tinnitus (388.30, tinnitus, unspecified). His internist sent him to the hospital for a consultation with an otolaryngologist. Lets suppose the otolaryngologist removed wax from the patients ear and gave him an audiogram.

The coding still would have been as follows: 69210 for the cerumen removal, 9924x-25 for the E/M, and 92557 for the hearing test. The HCFA 1500 form would include diagnosis codes 388.30 (for tinnitus) and 389.9 (unspecified hearing loss). The tinnitus diagnosis would be linked to the 9924x E/M code, while the 389.9 would correspond to the audiogram. The audiogram would assist the physician in diagnosing hearing loss, which in turn causes the tinnitus. The 69210 would have a corresponding 380.4 diagnosis code.

If the patients carrier conformed to Medicare guidelines, the otolaryngologist would be reimbursed for the audiogram and for the E/M, while the cerumen removal would have been included in the hearing test and would not be paid.