Otolaryngology Coding Alert

These 5 ear-procedure do's and don-ts will get money in your door faster

If you have the inside scoop on Medicare's carve-out policy for 69210/modifier 25, you can focus on winnable denials and get the best ethical pay-up for encounters involving an office visit, impacted wax removal, and/or microscopy

Insurers are bundling 69210 (Removal impacted cerumen [separate procedure], one or both ears) and 92504 (Binocular microscopy [separate diagnostic procedure]) with a same-day E/M service (such as 99213-25, Office or other outpatient visit for the evaluation and management of an established patient -; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Sometimes, you should appeal for payment, but in other cases the payer is right. Test whether you-re zooming in on worthwhile appeals with the following sample claim.

Case study: A payer denies microscopy when billed with impacted cerumen removal. The claim contains:

- 99213-25, 389.10
- 69210, 380.4
- 92504, 389.10.

Don-t: Report 69210 and 92504 Together

Solution: The claim should contain only one procedure code. -You can code either the impacted cerumen removal or the microscopy, not both,- says Julie Keene, CPC, an otolaryngology coding and reimbursement specialist at University ENT Specialists in Cincinnati. These codes are listed as -separate procedures- in the CPT book.

Procedures with descriptors containing this term -are commonly carried out as an integral component of a total service or procedure,- state CPT's separate-procedure notes. These codes -should not be reported in addition to the code for the total procedure or service of which it is considered an integral component,- according to surgery guidelines.

Impact: When a physician performs a separate procedure and another procedure in the same area, CPT includes the separate procedure in the other procedure, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. So, if the otolaryngologist does anything in the ear and microscopy, CPT includes 92504 in the other ear procedure and the microscopy is not billable. Similarly, if the ENT performs any ear procedure and also removes impacted cerumen, 69210 is included in the other ear procedure and is not billable.

Do: Realize Payers Treat 69210 as Incidental

Because you should bill only 69210 or 92504 in the above claim, you should first look at the problems caused by reporting an office visit in addition to 69210.

On claims for an office visit and 69210, Medicare will only pay for the office visit, says Brenda Kohli, with ENT Head & Neck Specialists PA in Wyomissing, Pa. -I have tried modifiers with no luck,- she adds. The carrier will pay for 69210 when Kohli bills the procedure alone.

Medicare usually allows you to bill an E/M service that meets modifier 25 criteria with a minor procedure, one that has zero or 10 global days. -If the physician has performed and documented an E/M service that was separate from the normal -preoperative- workup prior to removing impacted cerumen, you may report the E/M with modifier 25 in addition to 69210,- says Marie West, CCS-P, CMSCS, CCP, a national coding educator and president of Coder eSource, a coding and compliance education and consulting firm in Edmond, Okla.  

Exception: -Medicare through its carriers is carving out 69210 from the usual modifier 25 rules for minor procedures,- Cobuzzi say. Medicare policies consider impacted cerumen removal such a minor procedure that they always include it in the E/M--or vice versa depending on carrier--regardless of modifier 25.

Here's how one insurer explains its bundle of E/M with 69210. M-Care (owned by Blue Care Network and Blue Cross Blue Shield of Michigan) considers 69210 an incidental procedure, one that is typically performed at the same time as a more complex primary procedure. Because an incidental procedure requires little additional physician resources, and/or is clinically integral to the performance of the primary procedure, incidental procedures are not reimbursed separately, according to the M-Care Provider Manual. Example: -If 69210 is billed in conjunction with 99212, 69210 is considered incidental to the office visit code (99212) and is NOT reimbursed separately,- the manual states

Best bet: When billing a carrier that won't pay 69210 and an E/M, report only one code. -Compare relative value units (RVUs) for 69210 versus the E/M and bill the code with the higher relative value unit,- West says. The 2007 Medicare Physician Fee Schedule assigns 1.27 RVUs to 69210. So if you-re weighing reporting 69210 or 99213, which has 1.66 RVUs, pick the E/M. But in the M-Care example 69210 has a higher value--99212 contains 1.02 RVUs.

Don-t: Think 69210 Is Unwinnable on Appeal

When you have documentation that supports a separate and significant E/M and 69210, weigh how much time and staff resources you have available to appeal a procedure that only pays about $38.66 (1.02 RVUs x 37.8975 conversion factor). Consider two options depending on the diagnoses the otolaryngologist listed.

Option 1: Appeal denials for well-documented ear-related claims. Although CPT doesn't require different diagnoses on claims involving modifier 25, using separate diagnoses for the E/M and 69210 will help show the payer the individual reasons for each. If a patient comes in complaining about a problem with her ears, such as decreased hearing, fullness or pressure, use that as the service reason. For instance, -if a patient comes in with ear pain, I will code the ear pain with the cerumen impaction (380.4, Impacted cerumen),- Keene says.

Appealing denials for cerumen impaction with an office visit in which the documentation truly supports an E/M and removal of cerumen impaction may be worth your time. In the six cases Keene has appealed this year, she's been denied on one and paid on five.

Option 2: Limit appeals to unrelated claims. When appealing 69210 denials, you will find a higher success rate when the E/M is for a non-ear reason, Cobuzzi says. Examples: A patient has an E/M for a sinus problem (such as acute pansinusitis 461.8) or sore throat (462, Acute pharyngitis) in addition to impacted cerumen removal. -The anatomically unrelated diagnoses help prove the separate nature of the 69210 from the E/M-25,- she says.

Do: Opt for Hassle-Free 92504-E/M Combo
 
The unrelated-diagnoses caveat, however, doesn't affect microscopy-E/M claims. -It's easier to get paid on 92504 with an office visit using one diagnosis than it is to get paid for 69210 with an E/M-25,- Cobuzzi says.

Impact: On encounters involving an office visit, cerumen impaction and microscopy, some practices are choosing to bill the E/M with the scope instead of the cerumen impaction as long as they have documentation that supports the 25 service. This method is financially beneficial. -They-re getting paid more reporting 92504 and the office visit than with a 69210 and the E/M-25,- Cobuzzi says.

For instance, coding a documented standalone level-two established patient visit, impacted cerumen removal and microscopy claim with 99212-25 and 92504 could result in an extra $28.04 right off the bat (92504 has 0.74 RVUs [x 37.8975 CF]), rather than having to deal with the uncertainty of payment after initial appeal for 69210 with 99212-25.

Do: Test Your ICD-9 Savvy

Apply your related/unrelated diagnoses skills to the 99213-25 with 92504 and 69210 claim listed in the case study. The microscopy and the office visit are for the same reason: 389.10 (Sensorineural hearing loss, unspecified). Codes 99213-25 and 69210 contain separate but anatomically related diagnoses--both 389.10 and 380.4 are ear problems.

Final solution: Because getting paid for an impacted cerumen removal that is related to an office visit is hard to come by, Cobuzzi advocates coding this claim as 99213-25 and 92504 with both CPT codes linked to 389.10.   

Must: Make sure documentation supports the E/M as significant and separately identifiable from 92504. The service reason doesn't have to be different from the scope reason, Cobuzzi says.

The E/M can be the decision to do the workup. For instance, the otolaryngologist might state he needed to use the microscope to help clean the ear out, Cobuzzi says.