Pediatric Coding Alert

Plus: CCI weighs in on the issue.

It’s been active for over a month now, but new code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) has stymied many pediatric practices across the country. After all, you’ve been told for years that you can’t report cerumen removal that doesn’t require instrumentation—so how does this new code suddenly allow you to collect for it?

Although the new code’s introduction was welcomed by many pediatricians, its debut didn’t convince anyone that it would be payable. However, new information from one payer and a medical association is beginning to shed light on how to report 69209. Read on for the early instructions on how to bill this new code.

Ensure That It’s Medically Necessary

You can’t report cerumen removal unless your documentation demonstrates that the procedure is medically necessary and documents the fact that the cerumen is impacted.

Medical societies are reminding physicians to confirm the impacted nature of the cerumen in their notes. “Irrigation for nonimpacted cerumen is part of the physician’s/QHP’s E/M code and not separately reported,” the Indiana Osteopathic Association says in its document, “2016 Coding and Billing Update.” In addition, removing the impaction must be medically necessary—it can’t simply be because the patient asks for you to clean her ears out.

You’ll collect about $13 when you report 69209, based on the 2016 Medicare Physician Fee Schedule.

Be Careful With E/M Codes

If your pediatrician is inspecting the patient’s ears during an exam and then irrigates the ear as part of the E/M service, you may not be able to collect for both services unless you use a modifier and your documentation is extremely thorough.

Paramount Healthcare, a payer in Ohio, has released a medical policy on how to report 69209—one of the first insurers to do so. Paramount’s policy states, “Payment may be made for both removal of impacted cerumen and an evaluation and management (E/M) service (with appropriate modifier appended), only if the E/M service represents a medically necessary, significant and separately identifiable service that is supported by medical record documentation.”

Paramount stresses that the documentation should clearly support that a significant amount of the clinician’s time and effort were required. “This includes a procedure note supporting the time, interventions and how the patient tolerated the procedure,” the policy says. “The time spent removing the cerumen cannot be included in the time spent performing the E/M service. If the cerumen must be removed in order to examine the ears, the removal is considered a component of the examination portion of the E/M service.”

Remember That 69209 Is Unilateral

CPT^® codes 69209 and 69210 (Removal impacted cerumen requiring instrumentation, unilateral) describe a unilateral procedure, CPT^® notes. To report a bilateral service, append modifier 50 with “1” in the unit field, Paramount says.

Therefore, irrigating both ears to remove impacted cerumen would appear this way on your claim:

69209-50 linked to ICD-10 code H61.23 (Impacted cerumen, bilateral).

Make Sure Healthcare Professional Is Available

If one of your clinical staff members irrigates the patient’s ear to remove impacted cerumen, ensure that he isn’t in the office solo. According to the Indiana Osteopathic Association, “When performed by clinical staff, billing physician/QHP must be physically present in the office and immediately available.”

Don’t Report 69209 With 69210

You cannot submit both 69209 and 69210 together for the same ear, CPT^® says. Although the Correct Coding Initiative (CCI) bundles 69209 into 69210, a modifier can be used to separate the edit when separate ears are addressed.

For example, if you perform cerumen removal using lavage on the left ear and using instrumentation on the right, you can report 69210-RT and 69209-LT for payers that accept the right and left side modifiers. If not, you should report 69210 followed by 69209-59.

Check Out the Remaining CCI Bundles

Both codes for cerumen removal (69209 and 69210) are listed in the new edition of CCI (Version 22.0) as the Column 1 procedure in more than 200 edit pairs. The bundled procedures range from simple wound repair and nerve injections to extended breathing tests and EEG monitoring. Most represent situations when your pediatrician probably would not be performing both procedures during the same encounter, but take a look at the pairings just to be aware.

Switch up: The role of 69209 changes when paired with most audiologic function tests (92550-92596). In these edits, cerumen removal is bundled into the test procedure so should not be reported separately. The same holds true when your physician wants to report 69209 with auditory function tests (92620-92627): report the test, not the cerumen removal since audiologic function testing and auditory function testing cannot be performed without first cleaning out the patient’s accumulated cerumen in the ear.