Otolaryngology Coding Alert

Question: One of our physicians would like us to create a letter for commercial payers asking that they reconsider payment for 69210 with an E/M code since Medicare now states that the procedures are not inclusive of each other. He wants us to point out that Medicare and Cigna are now paying as separate codes that they should follow with that same decision. Is it possible that they will reconsider their decision? Or would this be a waste of time? 

New Hampshire Subscriber

Answer: It’s never a waste of time to contact a payer about reimbursement if you believe your request is justified and you have documentation to support it. 

Payers should reimburse for 69210 (Removal impacted cerumen requiring instrumentation, unilateral) with an E/M code during the same encounter if the circumstances meet the criteria. Verify that you have a separate, significantly identifiable diagnosis for the E/M visit and the impacted cerumen. If your provider’s documentation supports the separate issue, you should be paid for both codes without needing to appeal. 

Specifically, you can get support for payment of a separate and significantly identifiable E/M with the removal of impacted cerumen from the AAO/HNS website if you are a member.  They state: “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.

When all four items above are met, you have what you need to both use a 25 modifier with the E/M service and the 69210 as well as appeal any denials you receive.  Do not just accept a denial of your appeals, fight with the payer, request that a Board Certified Otolaryngologist review the appeal and request a meeting with the Medical Director should the appeal get denied as a second level appeal.

You can find the AAO/HNS guidance once you log on to the Academy website using your username and password at http://www.entnet.org/content/cpt-ent-cerumen-removal