Otolaryngology Coding Alert

Question: When we bill cerumen removal with office visits and audiology testing, the cerumen removal is denied as payment included in main procedure. We attached modifier -25 to the E/M code and bill 69210 with 380.4 and the E/M or audiology codes with a separate ICD-9. The appeals we file are also rejected. Can you help?

Michigan Subscriber

Answer: Many local Medicare carriers employ strict policies that narrowly define how and when evaluation and management (E/M) services and cerumen removal (69210, removal impacted cerumen [separate procedure], one or both ears) are appropriately billed separately.

For example, according to an Oct. 18, 2000, policy from HGSA (formerly Xact), the local carrier in Pennsylvania, payment consideration may be made for both the procedure and the E&M service if all [emphasis added] of the following conditions exist:

The nature of the E/M visit is for something other than removal of impacted cerumen.

During an unrelated patient encounter (visit), a specific complaint or condition related to the ear(s) is either discovered by the physician or brought to the attention of the physician/non-physician practitioner (NPP) by the patient.

Otoscopic examination of the tympanic membrane is not possible due to a cerumen obstruction in the canal.

The removal of impacted cerumen requires the expertise of a physician or NPP and is personally performed by the physician or NPP.

The procedure requires a significant amount of the physicians/NPPs effort and time.

Documentation is present in the patient record to identify the above criteria [have] been met.

A second diagnosis code is needed because E/M services are unlikely to be considered medically necessary with a diagnosis of 380.4 (impacted cerumen). This diagnosis code should be used when billing 69210 alone (or should be associated with cerumen removal only if more than one service is provided).

Assuming the E/M is performed for a different problem, the likely reason for the denials would seem to be that audiology tests were also performed. Although CPT does not prohibit billing cerumen removal and audiologic testing, Medicare will not pay for cerumen removal on the same day as an audiogram (92557, comprehensive audiometry threshold evaluation and speech recognition), says Gretchen Segado, chief compliance officer at Jefferson University in Philadelphia, even though ear wax removal can take as long as half an hour using sophisticated equipment. Medicare reasons that because the physician cannot perform audiology without cleaning the ears if they are full of wax, cerumen removal is included in the audiology code.

The latest version (7.0) of the national Correct Coding Initiative continues to bundle cerumen removal with audiograms. The edits include 0 indicators, which means they cannot be bypassed by using modifier -59 (distinct procedural service).

If Medicare carriers are denying cerumen removal when performed only with an E/M, the otolaryngologists documentation should be examined. Some otolaryngologists provide insufficient documentation, consisting of notes that state little more than that the patient was referred by a primary care physician, had wax in his or her ears, the wax was removed and the patient is to return as needed. As evidenced by HGSAs requirements and those of other carriers, such a note would not substantiate billing both for E/M services and cerumen removal.