Otolaryngology Coding Alert

Question: We have a few insurance companies who deny an office visit with 69210. We used modifier 25. Any other suggestions?

California Subscriber

Answer: You should report an E/M service on the same day as removal of impacted cerumen only when the E/M is for a separate and different condition from the impacted cerumen which required the 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) -- for instance, if the patient had a cough.

When your ENT's documentation supports a separate, significant E/M service in addition to cerumen removal, you should (and rightly did) append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M service code.

Unlike other uses of modifier 25, 69210 is one of the few codes which will not accept only one diagnosis for both the E/M and the procedure, even when the patient arrived with an unknown complaint and received a full work-up that resulted in the removal of the impacted cerumen. Medicare and most private payers will not pay for both an E/M and 69210 on the same day with only the diagnosis of 380.4 (Impacted cerumen)

Example: If the patient has pain in the external ear as her only complaint and the surgical removal of cerumen addresses that complaint, you should bill only for removal of the cerumen (69210). If, however, the patient also has symptoms of otitis media (such as 382.00, Acute suppurative otitis media without spontaneous rupture of ear drum) that require evaluation, and the physician performs and documents a separate evaluation for this problem, you should report the appropriate E/M service level, with modifier 25 appended, in addition to 69210. Code 69210's descriptor specifies removal of impacted cerumen. To use that diagnosis, your otolaryngologist must state "impacted" cerumen. Most payers restrict 69210 pay to a diagnosis of 380.4.