Pediatric Coding Alert

Experts reveal the diagnoses and modifiers insurers want on cerumen removal, E/M service claims

Payers may seem notoriously difficult when you’re trying to obtain E/M service payment with impacted cerumen removal--but the ICD9 Codes and modifier you use can make the difference between denial and deserved dollars.

“When a pediatrician performs removal of impacted cerumen, may I also report an E/M service?” asks Phyllis Matarese, billing manager at Winthrop University Hospital in Bethpage, N.Y. “Or should I bill only one or the other, depending on what the physician did?”

Although circumstances and documentation may justify reporting both the service and the procedure, “insurers rarely pay both,” says Sharon Newman, CPC, coding education and documentation coordinator at Children’s Specialty Group in Norfolk, Va. Try these strategies, which can help you recoup payment for performed and documented 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) services in addition to 69210 (Removal impacted cerumen [separate procedure], one or both ears).

Tip 1: Assign Separate Diagnoses

You must report two diagnoses for claims involving a sick visit and impacted cerumen removal. “Otherwise, the insurer will bundle the E/M service into 69210,” Newman says.

Key: The documentation must support both ICD-9 codes. “The only appropriate diagnosis to use with 69210 is 380.4 or impacted cerumen,” Newman says. The other diagnosis to support the E/M code may represent ear pain (388.7x, Otalgia), otitis media (381-382) or another illness (such 465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site).

Example: A child complains of ear pain. Impacted cerumen blocks the eardrum, preventing the pediatrician from examining the ear. The pediatrician uses an otoscope and curette to remove the impaction. She then examines the ear and diagnoses the patient with acute purulent otitis media.

In this case, you have two diagnoses--382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum) and 380.4 (Impacted cerumen). You should use the otitis media diagnosis (382.00) for the E/M service, and impacted cerumen (380.4) for the procedure. The different ICD-9 codes help show the insurer that the pediatrician performed a separate E/M service from the cerumen impaction removal.

Tip 2: Attach Modifier 25 to E/M Service

Another tool that will substantiate 99212-99215 as separate from 69210 is modifier 25. When a pediatrician removes impacted cerumen prior to assessing a child for otalgia or otitis media, the procedure is not part of the visit, says Catherine A. Hudson, RMA, RPT, practice manager at Cumberland Pediatrics PC in Marietta, Ga. “The physician can’t tell what’s going on with the ear until she can visualize the ear drum.”

Bottom line: The pediatrician performs the ear examination to assess the patient’s ear pain complaint and for otitis media. The impacted cerumen removal treats the impaction, which is a separate condition from the child’s potential ear infection.

Try this tactic: To show the insurer that the service is separate and significant from the impacted cerumen removal, consider appending 99212-99215 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

“The pediatrician chooses the level of visit with the diagnosis that shows what’s wrong with the child’s ear” and codes the cerumen removal with the impacted cerumen diagnosis, Hudson says. “I then append modifier 25 to the E/M service code.”

When Hudson reports 69210 and 99212-99215 with different diagnoses, she finds that most insurers including United HealthCare and Cigna want modifier 25 on the E/M service code. Georgia Medicaid, however, bundles the office visit with the cerumen removal. “Its policy states that the carrier will pay for only one or the other,” Hudson says.

Best practice: When an insurer will pay only the cerumen removal or the modifier 25 appended E/M service, you should still bill properly, Hudson says. Accurate records will enable you to document how much a payer’s policy financially affects you.

Tip 3: Consider Modifier 59 as an Option

CPT guidelines support using modifier 25 on an E/M service with cerumen removal, but insurers may think  differently. “Some payers don’t want modifier 25,” Hudson says. They prefer modifier 59 (Distinct procedural service) on 69210. You should use modifier 59 only on the procedure code, not on the E/M code, says the Georgia Chapter of the American Academy of Pediatrics.

Action: You have to learn insurance companies’ policies on 69210 with 99212-99215. “Although the payer’s method may be incorrect based on CPT rules, you should follow the insurer’s coding guidelines,” Hudson says. When an insurer supports a coding policy that is inconsistent with CPT, obtain the recommendation in writing.