Pediatric Coding Alert

Question: I read that Medicaid will pay for 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler, or IPPB device) when billed with other nebulizer services if modifier 59 (Distinct procedural service) is attached, so I've been putting it on all my 94664 charges and it has worked. I am also appending modifier 59 to all of my 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) charges when we bill it with an E/M service. However, I don't want to signal any red flags to an insurer by overusing modifier 59, so can you tell me if I'm using it correctly?

Rhode Island Subscriber

Answer: The answer regarding the 94664 issue depends on which other services you're providing during the same visit. For instance, if you report it with 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction...), most insurers would require you to append modifier 59 to 94664 because the CCI bundles those two codes. You would need to use modifier 59 to tell the payer that both procedures were performed as separate, distinct, medically necessary services (assuming your documentation supports that).

As for 69210, you should not use modifier 59 when you're reporting the cerumen removal with an E/M service. Modifier 59 only applies when you're reporting two procedures, but in this case you are reporting an E/M and a procedure, so modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be more appropriate.

The problem is that many payers are not reimbursing practices even with the 25 modifier appended-- they are paying for either the E/M or the removal of the impacted cerumen. This is one case where one diagnosis, the impacted cerumen, may not cover both the E/M and the 69210. You might need two different diagnoses for most payers to reimburse you for both procedures, linking the impacted cerumen diagnosis code (380.4) to 69210 and any other diagnosis, such as otitis media (382.00) or otalgia (388.70), with the E/M service code (typically 99212-99214) with modifier 25 appended.