Pediatric Coding Alert

When a pediatrician sees a patient and determines that its necessary to remove impacted ear wax, there are usually two codes used: 69210, for removal of impacted cerumen, and an office-visit code. To get paid for both, its necessary to affix the -25 modifier to the office-visit code. However, there can be problems getting paid for both, because some insurance companies are refusing to recognize the -25 modifier.

The case is explained succinctly by Heather Elsesser, accounts manager for Candlewood Valley Pediatrics, a three-pediatrician practice in New Milford, CT. Were having problems being reimbursed for modifier 25 visits, Elsesser writes. The example she uses is a visit for removal of impacted cerumen, which, in her office, is usually CPT 99213 . Our office visit charge is $43, she writes. Our charge for 69210 is $15. Were finding were only being reimbursed $15, and the $43 needs to be adjusted. This is happening mostly with one carrier. Some other carriers are paying the office-visit code, and not the cerumen removal. Are we coding this correctly?

The answer is yes, you are coding it correctly.

This is what modifier -25 is for, according to CPT:
Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service.

But, to get reimbursed, you may have to code differently. We received this advice from two billing experts who have had a similar experience.

1. Use the -25 modifier, but look for additional diagnoses, and use them first. This is the best way that Judy Williams, coder for Daniel L. Thornton, MD, FAAP of Vero Beach, FL, has dealt with the problem of an office visit and cerumen removal. A lot of times the doctor has found more than one diagnosis, says Williams. There may be an upper respiratory infection, or otitis media. If there is more than one diagnosis (besides impacted cerumen), then she uses the other diagnoses in the top slots on the claim form. I put the -25 modifier on the office visit, but list the impacted cerumen diagnosis last, she says. What if there are no other diagnoses? Then we dont bill for the cerumen removal at all, says Williams. At least we get paid for the office visit that way. The problem, as Williams [...]