Otolaryngology Coding Alert

Search back through your external auditory canal foreign body removal (FBR) claims, because you may be able to appeal any denials you received since Jan. 1. The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) overturned an edit that prevented bilateral payment for 69200 (Removal foreign body from external auditory canal; without general anesthesia). Up until Oct. 1, CMS designated that the 150-percent bilateral payment adjustment did not apply, but no more.

"Wow, that's great! Good work, AAO," cheers Karla M. Westerfield, COPM, business manager for Southeast Wyoming Ear, Nose & Throat Clinic PC in Cheyenne. Make Sense of This Change Coders maintain this change follows common sense. "Payers should reimburse physicians additional money when performing the procedure on both ears rather than just one," says Candice Ruffing, CPC, CENTC, surgical coding specialist for a physician practice in Port St. Lucie, Fla. "Two ears means additional time and work involved."

"Just as we can charge bilaterally for PE tube insertions, we should be able to charge to bilaterally remove anything from the ear canal," Westerfield agrees. Look at the situation this way. "The Correct Coding Initiative (CCI) shows 62900 as a component of 69205 (... with general anesthesia) with a modifier indicator of '1.' Since the '1' indicates you may, under appropriate circumstances, bill both codes on the same date of service for a patient, one can conclude this edit already acknowledges a physician can work on two different ears (one with anesthesia, one without) and receive reimbursement for both," says Jean Acevedo, LHRM, CPC, CHC, CENTC, president and seniorconsultant for Acevedo Consulting Incorporated in Delray Beach, Fla. "I'm delighted theAAO-HNS's work on behalf of its member physicians overturned an edit that never made sense."

Suppose a 4-year-old child placed pebbles in both his ears. His mother brings him to your otolaryngologist for removal of the pebbles. The child's private payer follows the CMS fee schedule for the application of modifiers. Your otolaryngologist removes the foreign bodies from each ear, billing 69200-50 (Bilateral procedure). Note: Some private payers prefer 69200 on the first line and 69200-50 on the second line).

The Medicare fee, not adjusted for geography, will be 150 percent of $108.92 or $163.38. A private payer will have a fee higher than the Medicare fee schedule -- but that's at least a $54.46 increase to your bottom line. With possible tough times ahead in 2010, "any decision that results in potential higher payment is a welcome relief," Acevedo says.

CMS will add the change to the fee schedule as of Oct. 1, but it will be retroactive to Jan. 1, 2009. If you received any denials for dates of service during that time frame, then you should be able to appeal.

"If you did not append modifier 50 to original bilateral 69200 claims, then you need to resubmit," Acevedo says. "Your payer will not be able to determine on its own which claims may now require higher reimbursement."

Also, you need to contact your payer to "see how the payer wants 69200 annotated on the claim. This will help insure you don't receive a rejection due to a duplicate claim or receive the full 150 percent of payment for the FBR, if your practice already received the reimbursement for one side," she adds.

Experts advise that you include in your appeal letter an explanation as to why you're resubmitting the claim and seeking reimbursement for the bilateral external auditory canal FBR. Resubmitting the claim will not be sufficient. You must submit an appeal to receive payment.

Another roadblock that may be encountered could be the 120-day limit for filing appeals. "Not all payers will let us go back to January 2009 and correct a claim," Ruffing says.

Do this: Again, explain in your appeal you could not meet the 120-day time limit given that the repeal of the bilateral edit did not take place for as long as 10 months later (should the appeal be for a January claim, for example). You may have to file an appeal to the second level (reconsideration), if a payer denies the first level (redetermination), for timely filing.