Otolaryngology Coding Alert

Question: The major Florida carriers, except for Humana, paid G0268 in 2006. We are having trouble getting the code paid in 2007. The explanation of benefits (EOB) states the code is incidental to the E/M service. The claims have a modifier 25 attached to the E/M, and the E/Ms have other unrelated ICD-9 codes attached. What happened in 2007 to change these payers- policies?

Florida Subscriber

Answer: Not all third-party payers recognize G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing). Medicare requires G0268 for removal of impacted cerumen by a physician on the same day as audiometric testing.

If a payer does not recognize G0268, you should use 69210 (Removal impacted cerumen [separate procedure], one or both ears) if the otolaryngologist performed a medically necessary removal.

Example: An otolaryngologist sees a patient in his office for a scheduled audiometric function test. On examination, the physician notes impacted cerumen in both ears. She removes the impacted cerumen and sends the patient down the hall to her audiologist for tympanometry.

You should report'the proper-level office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ,,,) with the patient's complaint (for instance, hearing loss, 388.40, Abnormal auditory perception, unspecified).

To indicate that the office visit is significant and separate from the testing, append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 9921x. Report the impacted cerumen removal by a physician prior to audiologic function testing with G0268 linked to 380.4 (Impacted cerumen).

For the audiometric testing, assign 92567 (Tympanometry [impedance testing]) linked to the audiologist's findings, such as sensorineural hearing loss (389.1x). Code G0268 designates that the physician removed the impacted cerumen at a separate encounter from the audiometric function testing.

Problem: Your insurers are considering the impacted cerumen removal inherent to any E/M service -- even one for a separate reason from impacted cerumen. To fight these denials:

1. Involve other otolaryngology practices in Florida: the Florida Otolaryngology Society and the Florida Medical Society.

2. Send in supporting documentation highlighting the July 2005 CPT Assistant Surgery: Auditory System Q&A that addressed proper coding of 69210. Although the AMA's advice on coding the binocular microscope and 69210 is incorrect -- 92504 (Binocular microscopy [separate diagnostic procedure]) and 69210 are separate procedures that you should not code together -- the rest of the information is correct and supports your position.

3. Also explain that CMS pays for G0268 in addition to an E/M service when the criteria that your otolaryngologists have documented in these cases are met. Get the five criteria and CMS- E/M and cerumen removal policy from the American Academy of Otolaryngologists-Head and Neck Surgeons at www.entlink.net/practice/resources/New-Cerumen-Removal-Code-G0268.cfm.

-- You Be the Coder and Reader Questions answered/reviewed by Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.; and Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City.