Otolaryngology Coding Alert

Question: I bill 94664 with other nebulizer services (for example, 94640, A7003, J7611, and 94760), and append modifier 59 to this CPT®. So far, my claims have worked with insurance companies pretty well. However, I'm worried that I may be overusing modifier 59 because I also tend to use it on 69210 billed with an E/M code. Is my use of the modifier justified or does another modifier apply?

Delaware Subscriber

Answer: First of all, don't forget that when you add modifier 59 (Distinct procedural service), you should bill the 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) with another service. Since this seems to be what you do, it means you're on the right track. The modifier 25 is only for use with E/M services, not procedural services.

On 69210 (Removal impacted cerumen [separate procedure], 1 or both ears), however, you should not use modifier 59 because you're reporting the CPT® with an E/M. Stick with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and then appeal with documentation if necessary. Then again, many payers would not reimburse with modifier 25 either. They usually pay for either the E/M or the removal of the impacted cerumen.

What to do: Since this is one case where one diagnosis -- the impacted cerumen -- will not cover both the E/M and the 69210, you should report two different diagnoses to get paid for both the E/M and 69210. Make your case stronger by linking the impacted cerumen (380.4) to 69210 and another one, such as headache (784.0), post nasal drip (784.91), or Eustachian tube dysfunction (381.81) with the E/M service.