Pediatric Coding Alert

Question: What modifier should I use for “bilateral procedure”? Should I use a single line item for the procedure (such as cerumen removal), or should I use the modifier the second time I bill the code? For example, should I code bilateral impacted cerumen removal as:

• 9921x -- dx otalgia or hearing loss
• 69210 -- dx impacted cerumen
• 69210-xx -- dx impacted cerumen.

New Jersey Subscriber

Answer: First, you should code cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) only once, regardless of whether the pediatrician removed the impacted cerumen (380.4) from one or both ears. The code’s description specifies “one or both ears,” so if you remove impacted cerumen from only one ear, modifier 52 (Reduced services) is unnecessary.

Tip: You can check whether a code qualifies as a bilateral procedure by checking column “Z” (labeled “BILAT SURG”) of the 2007 National Physician Fee Schedule. An indicator of “1” means you can append modifier 50 to the code. When you code procedures that qualify as bilateral, such as 28190 (Removal of foreign body, foot; subcutaneous), you should use modifier 50 (Bilateral procedure).

Check with payers for their modifier 50 filing requirements. Some payers may follow Medicare’s preference and want you to report the bilateral code using one line. For instance, a claim for removal of a splinter in each foot would contain:

• 28190-50.

Other insurers may want you to report the claim using two lines:

• 28190
• 28190-50.

Insurers may also adopt Medicare’s bilateral payment adjustment that pays modifier 50 services at 150 percent.

Error averted: You should report a medically necessary significant, separately identifiable E/M service (if performed and documented) by appending modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the office visit code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient É). So your cerumen removal claim could read:

• 9921x-25 -- dx otalgia (388.70, Otalgia, unspecified) or hearing loss (such as 389.9, Unspecified hearing loss)
• 69210 -- dx impacted cerumen (380.4).