Pediatric Coding Alert

Private payers may follow Medicare’s lead, which could hurt your bottom line.

When CPT^® clarified the language in CPT^® 2014 regarding cerumen removal, it seemed like good news. But thanks to a CMS rule, that news could be turning sour.

Background: CPT^® 2014 changed the descriptor for 69210 to “Removal of impacted cerumen requiring instrumentation, unilateral.” Therefore, most practices understood that they’d need to append a bilateral modifier (modifier 50) to 69210 when removing cerumen from both ears. Why? Although the descriptor for this code used to say “one or both ears,” it now specifically states “unilateral.”

Although this seemed like it might help open the door to bilateral reimbursement, the reality could be the opposite for payers such as Medicaid that follow CMS rules. The 2014 Medicare Physician Fee Schedule Final Rule states that CMS will “allow only one unit of CPT^® 69210 to be billed when furnished bilaterally,” citing the agency’s belief that both ears would be addressed most of the time “as the physiologic processes that create cerumen impaction likely would affect both ears.”

In other words, CMS believes that doctors will be removing cerumen from both ears more often than not, and claims that the code is therefore already valued for addressing both ears.

CPT® Clashes With CMS

Needless to say, this flies in the face of CPT^® guidance, which creates a quandary for pediatric practices. The American Academy of Otolaryngology has already stated that it has contacted CMS to resolve the issue. “We are seeking clarification from CMS regarding how to code and bill for this service given that the CPT^® code descriptor and code book are not consistent with the policy CMS has stated they will implement,” the Academy says on its website.

If your payer is following CMS’s rules on this issue, ask for a copy of the policy in writing. If the insurer does not have one, send your payer representative a copy of the CMS manual stating that 69210 is clearly marked as a unilateral code effective Jan. 1, 2014.