Otolaryngology Coding Alert

Official word comes from Medicare on stance, despite AAO-HNS objections. 

Otolaryngologists and physicians in some other specialties (such as family practice) have fought since early 2014 to gain bilateral payment for the removal of impacted cerumen, based on the CPT® 2014 manual’s description of service. Read on for the latest roadblock to that type of filing. 

Background: In previous years, the descriptor for 69210 read as “Removal impacted cerumen (separate procedure), 1 or both ears.” That changed this year, with a revised descriptor stating “Removal impacted cerumen requiring instrumentation, unilateral.” CPT® 2014 also includes a coding note directing you to append modifier 50 for bilateral procedures. 

The issue: When physicians began submitting claims with 69210-50 for bilateral procedures, some received denials because of the modifier. The primary payer refusing to acknowledge a bilateral designation for 69210 was Medicare, but some private payers followed suit. 

The reaction: The American Academy of Otolaryngologists – Head and Neck Surgeons (AAO-HNS) submitted letters to several payers about their policies that deny claims with 69210 is billed in conjunction with and office-based E/M code (99211-99215). The Academy also held a conference call with CMS on the matter, as noted previously in Otolaryngology Coding Alert (see “Watch for inconsistencies with 69210 payment before filing your claims,” Vol. 16, N. 3). CMS stance at that time was that the payment policy within the 2014 final Medicare Physician Fee Schedule would stand – no recognition of modifier 50 when filed with 69210. 

According to information on the AAO-HNS website, “Their [CMS] rationale for this is that CMS feels the physiologic processes that create cerumen impaction likely will affect both ears.” This rationale leads to the assumption that in the majority of cases the physician will be removing impacted cerumen from both ears. Therefore, CMS believes that 69210 should automatically cover treatment of both ears. 

Latest news: CMS has made a final decision that bilateral claims for 69210 will not be reimbursed. You’ll see this by looking at the 2014 Medicare Physician Fee Schedule, which shows that modifier 50 (Bilateral procedure) is not allowed with 69210.  Private payers may or may not recognize the bilateral modifier with 69210.

What to do: Based on this information, the AAO-HNS recommends that physicians not report 69210 using modifier 50 to Medicare since MACs are denying these claims entirely and sometimes not paying for the unilateral side. Check with any private payers to verify their latest positions before filing claims with commercial insurers. 

“We are working with [CMS] to provide them with concrete data related to the percentage of time 69210 is provided bilaterally, in hopes that this will allow them the necessary evidence to revisit this payment policy in CY 2015,” recent information on the AAO-HNS website states.

Keep a Check on E/M Claims

Practices are also finding that payers are denying E/M services when performed with the removal of impacted cerumen. The AAO-HNS makes it clear that these two services can be coded together, with a 25 modifier (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the E/M service in certain situations. According to AAO-HNS, “When reporting an E/M visit and cerumen removal on the same date of service (DOS), the following criteria must be met: 

1. The initial reason for the patient’s visit was separate from the cerumen removal.
2. Otoscopic examination of the tympanic membrane is not possible due to the impaction;
3. Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner and is personally performed by him or her; and
4. The procedure requires a significant amount of time and effort, and all of the above criteria are clearly documented in the patient’s medical record.”

The AAO/HNS also stresses that in addition to meeting the criteria above, it is important that the definition of modifier 25 be met when using it with an E/M service and 69210. The note should reflect that the removal of the impacted cerumen was a separate service. It also helps to have a different diagnosis associated with the E/M service from the diagnosis associated with the removal of the impacted. cerumen, advises Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Caution: Know, however, that appending modifier 25 and having separate diagnoses for the E/M visit and 69210 won’t automatically lead to payment. Some private insurers such as Cigna and Blue Cross/Blue Shield in certain areas still deny the claims.