Pediatric Coding Alert

Question: We are having difficulty getting some CPT Codes paid by insurance companies. The first is 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs trays, supplies, or materials provided]), which we use for fluorescein. Do we have the incorrect CPT code, or should we be providing documentation with the charge? The second problem is 69210 (removal impacted cerumen [separate procedure], one or both ears). Is there another code we can use to get this procedure paid?

Texas Subscriber

Answer: For your first question, the answer depends on exactly what youre billing for under the 99070 code. If this is just fluorescein dye for an eye exam, insurance companies will not pay you separately. The dye is considered part of the exam. In terms of 69210, some insurance companies elect to include this in the exam of the child with an ear infection.

Some pediatricians rarely bill this, except for in cases where there is extensive cleaning. In these cases, you must include a copy of the dictation so the insurer can see that this is not a routine case but something special that should be paid. You may need to talk to the medical director, who may not be a pediatrician, and explain the time and risk involved in this procedure. The benefit of having this conversation with the medical director, who really may not be aware of the extent of work involved, is that you may get the insurance company to change its policy of automatic rejection.

Although the fluorescein is definitely part of the office visit and not billable separately, there are times you can bill for the cerumen removal. Dont give up. Remember that otolaryngologists bill for this often with success. Here are two tips to remember:

(1) Always use a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the evaluation and management (E/M) service. Also, use the reason for the visit (fever, otitis media, upper respiratory infection, etc.) as the first diagnosis code on the E/M service.

(2) Always use the diagnosis code for impacted cerumen (380.4 on the 69210). Use no other diagnosis code on the 69210. Your documentation should support the impacted nature of the cerumen. The procedure should be a separate paragraph in the notes. Many insurance plans try to deny one service or the other, but if you fight, you may win.