Otolaryngology Coding Alert

Question: Can impacted cerumen removal by lavage be performed by a nurse?

Pennsylvania Subscriber

Answer: Yes. If this is a Medicare patient, the procedure can be billed incident-to, and here’s why and how.

The Medicare Physician Fee Schedule (MPFS) assigns a Professional/Technical Component (P/T) indicator of 5 to 69209 (Removal impacted cerumen using irrigation/lavage, unilateral). Per Medicare guidelines, this indicator “identifies codes that describe services covered incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision.”

In other words, you can bill for the procedure when performed by a nurse providing the following incident-to guidelines are met:

• The patient must be established with the physician;
• The provider has evaluated the patient’s condition during the face-to-face part of an evaluation and management (E/M) visit;
• The provider has established a plan of care for the patient; and
• The nurse or other auxiliary personnel is providing the service to help execute the patient’s care plan in part or whole.

However, you should remember the following before billing impacted cerumen removal this way:

• If incident-to requirements are not met for the service, the service must be provided and billed by the physician or a qualified healthcare professional (QHP) (e.g. nurse practitioner [NP] or physician assistant [PA]) under the physician or QHP’s UPIN/ PIN; and payment will be made at the appropriate rate established in the physician fee schedule. Services billed under an NP or PA’s provider number are paid at a lower rate than those billed under a physician’s provider number.
• Codes with a P/T indicator of 5, such as 69209, cannot be modified with modifier 26 (Professional component) or modifier TC (Technical component). This means you cannot divide up the service between the provider and others to receive extra payment on the procedure.
• Incident-to policies generally only affect Medicare payments. Private payers may well have different rules in place for procedures performed by QHPs or auxiliary personnel (e.g. nurse).

Impacted cerumen removal by instrumentation, coded to 69210 (Removal impacted cerumen requiring instrumentation, unilateral), has a P/T indicator of 0, meaning that the service must be performed by a physician or QHP and auxiliary personnel cannot provide the service incident-to the physician.