Otolaryngology Coding Alert

Question: When a Medicare patient presents to our office with a chief complaint of "hearing loss" and a cerumen impaction, the otolaryngologist removes the impaction under microscopic visualization. To detect any potential middle-ear contributions, the physician orders in-office tympanometry. I billed these services as 9921x, 69210, and 92567. Medicare, however, rejects 9921x and 69210, stating "payment adjusted because this procedure/ service is not paid separately." How should I submit charges for these services?

Ohio Subscriber

Answer: Depending on the impaction specifics of each case, you should file these claims using a different cerumen removal code. You can also combat denials with modifier 25 on the office visit code and separate E/M and test diagnoses.

To receive payment for a same-day cerumen removal and audiological test (such as 92567, Tympanometry [impedance testing]), you will have to report G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing) instead of 69210 (Removal impacted cerumen [separate procedure], one or both ears). Current CMS policy considers cerumen removal part of audiologic diagnostic testing and will not separately pay 69210.

Watch out: Medicare created the "G" code because it will not pay for the audiologist to remove the impacted cerumen in order to perform the testing. As such, Medicare needs to know that the physician -- not an audiologist -- removed the cerumen. Therefore, you should use G0268 only when the otolaryngologist performs cerumen removal prior to same-day audiological testing. Your otolaryngologist should not routinely perform this service. Rather, the cerumen removal must be too complicated for the audiologist to perform. In other words, it must be truly impacted, requiring physician skill and instrumentation to remove, so the otolaryngologist must perform the procedure.

You may, however, appeal the office visit denials.

Before doing so, check that you reported 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 (Significant,

separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Modifier 25 tells the carrier that the otolaryngologist performed a significant, separate office service from the audiological testing.

Your ICD-9 coding should demonstrate that the E/M is separate from the tympanometry. For the office visit diagnosis, you should use the patient's complaint of hearing loss (388.40, Abnormal auditory perception, unspecified). You would then link the audiologist's findings, such as sensorineural hearing loss (389.1x), to the test. Keep in mind: Most payers will not pay for an E/M service even with a supported 25 modifier if your diagnosis for this E/M code is the same diagnosis as the procedure (380.40).