Otolaryngology Coding Alert

Question: My new employer is insisting that the only way Medicaid will pay for removal of impacted cerumen bilaterally is to use modifier 76. However, I don’t think the description for modifier 76 applies in this situation. Who’s right?

AAPC Forum Participant

Answer: You are correct in saying that modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) would not be the correct way to bill bilateral impacted cerumen removal for Medicare or any other payer if the removal from both ears occurred during the same encounter. As Novitas Solutions notes, the modifier should be used “to indicate a procedure or service was repeated subsequent to the original procedure or service… on the same day, by the same physician or other qualified healthcare professional (QHP).”

If that is not the case, then coding and payment for bilateral impacted cerumen removal during the same encounter is dependent on the method used, which makes appending the correct modifier somewhat tricky.

Here’s why: According to CPT^®, both 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) and 69210 (Removal impacted cerumen requiring instrumentation, unilateral) are unilateral codes, which is why CPT^® instructs you to use modifier 50 (Bilateral procedure) on both codes when removal is bilateral.

But the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) notes that the Centers for Medicare & Medicaid Services (CMS) “feels the physiologic processes that create cerumen impaction likely will affect both ears.” Because of this both codes are viewed as inherently bilateral in CMS’ eyes.

So, CMS has designated a bilateral surgery indicator of “2” for 69210, meaning the procedure’s relative value units (RVUs) “are already based on the procedure being performed as a bilateral procedure.” In other words, “if the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT [Right side] and LT [Left side] modifiers or with a 2 in the units field)… the payment for both sides [is based] on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code,” per CMS’s valuation.

Consequently, the AAO-HNS “recommends that members NOT report 69210 using modifier -50, as MACs are denying these claims entirely and not paying for even one unit reported.” Additionally, the AAO-HNS notes “that some private payers are following CMS’ policy on this issue and are not reimbursing for this as a bilateral procedure.”

However, confusingly, CMS has given 69209 a bilateral surgery indicator of “1,” meaning that if you bill 1 unit of the code with the bilateral modifier, you will be reimbursed “the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code,” per CMS.

Why? CPT^® Assistant Volume 26, Issue 1 (January 2016) observes that “the removal of cerumen by irrigation or lavage usually takes longer to perform and may require additional staff time and equipment.”

What this means: Bilateral impacted cerumen removal by irrigation/lavage should be billed to Medicare with modifier 50 appended. This will ensure reimbursement at 150 percent of the current Medicare fee for the unilateral service.

However, you should not bill bilateral impacted cerumen removal by instrumentation with modifier 50, as reimbursement is the same for the service whether it is performed unilaterally or bilaterally. And you shouldn’t bill 69209 or 69210 with modifier 76 unless the patient has received the service before on the same day and is returning for a second, repeat service — an unlikely, though not impossible, circumstance that would require extensive documentation to prove medical necessity.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC