Pediatric Coding Alert

Removing impacted cerumen (69210) is a relatively common procedure in pediatrics, but understanding how to code for it is unclear. The big question is: Can you bill for the procedure codes for removing the cerumen and an office visit?

Debra Bales, billing representative for Orange-Irvine Doctors of Children in Orange, CA, writes to ask how to handle the typical scenario, in which a child has URI symptoms, the pediatrician looks in the ear to see if its infected and determines there is impacted cerumen, and performs an ear lavage to remove the wax.

This is another case in which some carriers will pay, and some wont, which could result in payment received from all carriers if you pursue the subject of payment.

1. Selective billing. Take the situation at Jacksonville Pediatrics where billing manager Kim Taylor charges insurance companies that will pay for the office visit as well as CPT 69210 , and doesnt bill those that dont. We used to file all the codes, but the pediatricians dont like to see a balance hanging, she says. But from an accounting aspect, it would be better to file it and know we were doing the work. In many cases, it would not be right to bill differently depending on carrier. But in fact, many carriers have specific rules regarding 69210 and office visits. Thats why fees for 69210 vary from $15 to $200, according to HealthCare Consultants of America 1999 Physicians Fee & Coding Guide. (The average range is $45 to $57, according to the guide.) Part of the variation relates to whether the physician routinely bills an office visit with the procedure or not, the guide states.

Tip: The office should bill differently only when required by contract. And if your contract says the company will pay only for the procedure, and not the office visitrenegotiate!

2. Modifier -25. Many coders agree that it would be best to bill for an office visit and the cerumen removal, regardless of whether the carrier will payat least theoretically. But in practice, if the carrier wont pay, how can you get reimbursed for both services? After all, the child didnt walk in and announce, I have impacted cerumen, please remove it. The pediatrician had to conduct a history and physical first to determine what was happening (fever, cold, etc.)thats the office visit. The cerumen removal is a procedure that is separate from the office visit.

Technically, you should use modifier -25 on the office visit to designate that it is a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Note that you do not need a separate diagnosis for the office visit and the cerumen removal. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided, CPT states in the definition of modifier -25. As such, different diagnoses are not required for reporting the E/M services on the same date.

It is true that you do not need a different diagnosis between the procedure and the office visit with the -25 modifier. However, cerumen removal is a case where you should always have a different diagnosis, says Thomas Kent, CMM, president of Kent Medical Management and a former office manager for a pediatric practice. The physician did not remove the ear wax to treat the fever the child came in for, says Kent. The illness or symptoms go on the office visit and not on the 69210. The diagnosis code for impacted cerumen380.4should always go on the 69210 and nothing else. The only reason for performing an ear wax removal is impacted cerumen.

Often, says Kent, office staff assume that the insurance plan is denying the combined visit because the company simply wont pay for both. But if you code with a separate diagnosis code and the -25 modifier, you are likely to be successful, he says.

3. Charge more for 69210. But even if you do use modifier -25, you may not get paid for both. Sheilla Hume, insurance manager for Raleigh Group Pediatrics in Memphis, TN, solves the problem by setting her fee schedule accordingly. Most pediatricians arent charging enough for 69210, she believes. I try to include the office visit and the procedure in our fee schedule. If you never intend to bill an office visit with the procedure, it makes sense to add the cost to the fee for 69210.

Pediatricians dont charge enough because theyre looking at the family, and dont want to make them pay any more, says Hume. But well always be underpaid if we do that. Were setting our fees at so much less than everybody else. What level office visit does Hume use when calculating the 69210-plus-office visit fee? We usually do a third-level visit with this procedure, so thats what I use, she says. The bottom line is that most pediatricians undervalue this service and have it set too low, says Kent. The fee survey quoted by HealthCare Consultants of America is based on what otolaryngologists are charging, not what primary-care pediatricianswho do a great deal more workshould be charging.

Kent recommends setting this fee high (near $150, but I will be satisfied with fees just below $100) and charging for the office visit in addition. The skill required for cerumen removal, when impacted, is greater than the pediatricians give themselves credit for, he says. If it were easy, then curettes would be available to the general public. Puncturing the ear drum is a real hazard, especially on small children.

4. Bilateral. What if you have to remove cerumen from both ears? You can charge only 69210 once; its defined as a bilateral procedure. That may be another good reason for practices to set the fee higherto allow them to get reimbursed adequately for the procedure when it is done on both ears.

5. Refer to otolaryngologist. This is the simple answer to the problemdont do 69210 at all. If you see impacted cerumen, send the child to an otolaryngologist for the procedure. Of course, this wont win you any awards from harried parents, especially if a child is cranky from an ear infection and there is another long wait in a waiting room to endure. But you will get paid for the office visit. On the other hand, insurance companies may look unfavorably to your referring too many patients for 69210, a fairly common procedure in pediatrics. But if you show them the difference in cost between your performing the procedure and the ENT doing it, they may be apt to change their policy and pay you for both the office visit and procedure.

6. Documentation. The medical record should have the ear wax removal documented separately from the office visit, says Kent. Simply skip a line after the exam portion of the note. State that the patient had impacted cerumen obstruction visualization of the ear drum. State which ear was involved. Describe the method of removal. Add mention of time only if unusually difficult due to patient motion or severe impaction. A copy of these notes will clearly show the insurance company that the cerumen was removed as a separate procedure.

Curette or Irrigation?

Even without the office visit complication, 69210 is a controversial code because it doesnt say how the cerumen is to be removed. Many pediatricians dont believe it should be used for a swipe of the curette. They think the code should be reserved for the lavage with the Water Pika much more extensive procedure, especially in pediatrics.

The lavage, or irrigation, does require more staff time and effort. A plastic bag has to go over the child so the child doesnt get wet. One staff member does the irrigation. Someone else has to hold the bowl under the ear and someone else has to help restrain the child. If its done in both ears, its quite a production. So its understandable that pediatric practices would think there would need to be more remuneration for lavage than for removal with a spoon.

But actually, it takes skill to remove ear wax from a child. Pediatricians tend to discount this and say, Oh, I wont charge for that, it took two minutes. But it also took extensive training and skill and experience. That is what you are charging for. And, in fact, practices are using 69210 for the curette or the syringe, as well as the Water Pik.

We dont have any problems getting paid for 69210,
and we use it for the Water Pik or sometimes just the curette, says Barbara Silva, office manager at Jacksonville, FL, Pediatric Associates.

Arthur Vecchiotti, MD, an otolaryngologist who specializes in pediatrics, says that 69210 has no restrictions as to method. Its for any means of removing cerumen, says Vecchiotti, who practices in Sleepy Hollow, NY. I can even suction it out, using a microscope. Yes, irrigation may be done as well. But regardless of how its done, the code is for the removal itself. Vecchiotti notes that he doesnt have any problem getting paid for an E/M service as well as 69210, providing the patient is a child. Most of the time, when Im seeing a child, the child must be examined for other problems as well, he says.

Kent agrees that you should not distinguish between methods of removal. I focus on the diagnosis, he says. If the ear wax is impacted, then it requires the skill of a physician, and charging 69210 plus an office visit is justified, he says. If the wax is soft and not obstructing the ear canal, or it could reasonably be removed with a Q-Tip, then consider it part of the office visit.

Finally, the Coders Desk Reference for 1999, published by Medicode, clearly states that 69210 is for cerumen removal regardless of how its done. Under direct visualization, the physician removes impacted cerumen using suction, a cerumen spoon or delicate forceps, the book states. If no infection is present, the ear canal may then be irrigated.