Otolaryngology Coding Alert

Question: Our MAC will only let us bill cerumen removal four times per year, but a Medicare patient insists on having the removal done a fifth time. What should we do?

Minnesota Subscriber

Answer: You should have the patient sign an Advance Beneficiary Notice (ABN) and explain to them that Medicare will consider the fifth cleaning "not medically necessary" and as such, Medicare will only pay for four cleanings and will not pay for the fifth cleaning.

As such, they will be required to pay for this cleaning themselves. The practice should not charge for an E/M in addition to the removal of the impacted cerumen unless it has an additional complaint unrelated to the impacted cerumen.

After the patients agrees, understands the ABN and signs the ABN, the claim should be submitted to Medicare with a modifier GA (Waiver of liability statement on file) indicating that an ABN is signed and on file. The rejection Explanation of Benefits (EOB) that the patient will receive will indicate the doctor may bill the patient for the service.

You may want to consider implementing a private pay version of the ABN or waiver so that your patients would be better informed. Well informed patients would subsequently result to better satisfaction. It is always a good idea to have your patients, with any insurance, to be pre notified and sign that they agree to pay for any service that may be considered non covered or not "medically necessary."