Otolaryngology Coding Alert

You deserve pay when the encounter meets 5 criteria

Thanks to CMS' reporting guidelines, you no longer have to wonder whether you should fight 9921x-25/cerumen-removal denials.
 
The problem: Medicare consistently denies an office visit with cerumen removal. Cindy Bryant, a claims administrator at Family Practice Specialists in Glennville, Ga.,  says that even when she has a separate diagnosis and uses modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), Medicare bundles the E/M service into 69210 (Removal impacted cerumen [separate procedure], one or both ears).

 When this happens to you, should you waste your time on an appeal? Coding experts say you should demand payment when your claim meets these CMS criteria:

1. E/M Is for a Different Reason

You should first verify whether the E/M visit is for anything other than cerumen removal, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J. CMS won't pay for an encounter in which the visit's intent and only documentation is for cerumen removal.
 
Example: A family physician (FP) refers a patient to an otolaryngologist for unilateral cerumen removal. The specialist looks in the patient's ear, sees impacted cerumen and removes it. In this case, bill the cerumen removal (69210) only, Cobuzzi says. Because the otolaryngologist didn't perform or document anything else, you can't support a separate E/M service.

2. ENT Performs Unrelated Service
 
You can, however, bill an office visit (99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...) or consultation (99241-99245, Office consultation for a new or established patient ...) when your otolaryngologist performs an unrelated patient encounter or the patient complains about his ears.
 
For instance, a patient presents with wheezing (786.07) and a fever (780.6) and also complains that he can't hear well. The otolaryngologist performs a level-three history, examination and medical decision-making, diagnoses the patient with an upper-respiratory infection (URI) and removes impacted cerumen.
 
In this case, you should bill both the service and the procedure. Here's how:

 1. Report the service that led to the URI diagnosis with the appropriate-level E/M, such as 99201-99215.
 2. Append modifier -25 to indicate that the service is a significant, separately identifiable service (meets CMS' fifth criteria, see section 5).
 3. Bill cerumen removal with 69210.
 4. Link the E/M to the URI diagnosis (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site), and the cerumen removal to impacted cerumen (380.4).
 
Hint: You will usually need two diagnoses when billing an E/M service in addition to cerumen removal. CPT doesn't require two diagnoses to report an encounter and a procedure. But CMS typically won't consider that dual cerumen-removal diagnoses justify coding an E/M encounter in addition to 69210.

3. Physician Can't View Tympanic Membrane

Before fighting for E/M payment, check your otolaryngologist's documentation. He must indicate that he could not examine the tympanic membrane with an otoscope due to impacted cerumen.
 
"This criterion shows Medicare that the otolaryngologist removed impacted cerumen to perform a medically necessary examination," Cobuzzi says. The removal is a precursor to the otoscopic exam.

4. ENT or NPP Performs 69210

Next, make sure the impacted cerumen required your otolaryngologist's or a nonphysician practitioner's expertise and that he performed the procedure. "This is CMS' fourth criterion for reporting an E/M in addition to 69210, Cobuzzi say.

5. Removal Requires Time, Effort

CMS' final requirement focuses on 69210's definition. You shouldn't bill cerumen removal to Medicare unless the otolaryngologist or NPP really has to spend a lot of time and effort removing the impaction.
 
That means he has to use instrumentation, such as a curette, to remove the impacted cerumen. If irrigation can remove the wax, the cerumen isn't really impacted, says Brenda Parker, coding specialist at Virginia Medical Alliance. In this case, the procedure work doesn't meet 69210's definition of "impacted cerumen" removal.