Primary Care Coding Alert

Experts reveal what wax removal coding really entails

If conflicting information on 69210's requirements is making you question when you should use this code, here's some good and bad news: CPT allows you to bill this code whenever your family physician (FP) removes impacted wax. But, payers may limit 69210 coverage to significant cases.
 
Family Practice Coding Alert experts suggested in the September 2003 issue that some Medicare carriers allow 69210 (Removal impacted cerumen [separate procedure], one or both ears) only with surgical instrumentation. Several readers disagreed with these recommendations.

"We queried National Heritage Insurance Company, Northern California's local Medicare carrier, on the method for cerumen removal," says Neil Knutsen, CPC, senior analyst at California's Palo Alto Medical Foundation reimbursement department, which serves 50 family physicians in four cities. The carrier representative indicated that 69210 requires no specific method(s).

So, Family Practice Coding Alert went back to our sources to verify what 69210 entails. Unfortunately, no black-and-white answer exists on the code's requirements. After extensive research, our exclusive conclusion is:

You should contact each insurer for its 69210 policy. "CPT offers no definitive explanation of 69210's requirements," says Marie Felger, CPC, Family Practice Management editorial advisory board member. Plus, no national Medicare policy exists on 69210. So, carriers and private payers may impose 69210 coverage restrictions.
 
CPT Leaves 69210's Requirements Open

CPT offers little guidance on what 69210 entails. "All CPT tells us is that 69210 is a unilateral or bilateral procedure," Felger says. Even CPT Assistant doesn't address the code.

In fact, CPT's creators, the AMA, also didn't mention any 69210 requirements. When the AMA presented information to CMS to help Medicare determine how many relative value units to assign to 69210, the issue never came up, says Felger, who attended the review update committee meeting. 

The bottom line: The committee based 69210's practice expense value on the amount of work involved in a typical cerumen removal case, not on the equipment or technique the physician might use. "No one said instrumentation or lavage," Felger says.

CDR Contradicts CPT

A common coding resource, however, indicates that 69210 requires instrumentation. "Under direct visualization, the physician removes impacted cerumen (ear wax) using suction, a cerumen spoon or delicate forceps. If no infection is present, the ear canal may then be irrigated," the Coders' Desk Reference (CDR) states.

Reason: CPT doesn't support the CDR description. You may use the CDR as a guide, but the book isn't the coding Bible. "Medicode, not the AMA, publishes the CDR," says Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan. Therefore, the CDR doesn't have the same authority CPT does.

Insurers May Restrict 69210 to Significant Cases

You can follow CPT's looser 69210 definition as long as the insurer doesn't impose additional restrictions. CPT guidelines allow you to report 69210 anytime the FP removes impacted cerumen, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, health information management certificate programs coordinator at Clarkson College in Omaha, Neb.

But, some payers limit 69210 to cases that involve a lot  of effort. If the removal requires only a little work, some insurers recommend billing only for the E/M service, Bucknam says. These policies may use instrumentation as a means of separating an insignificant procedure from a significant and billable 69210 service.

Example: Wellmark Blue Cross Blue Shield (BCBS) of Iowa and South Dakota considers 69210 a payable service only if the wax removal requires a significant amount of physician or supervised physician work based on time and instrumentation. The policy includes simple irrigation, drops installation and easily performed scrapings as part of the E/M service. 

Not all policies spell out the difference between significant effort and a nonbillable 69210 service. For instance, BCBS of Oregon and BCBS of Kansas -- which also covers Nebraska and northwestern Missouri -- cover cerumen removal only when the procedure requires a significant amount of time and effort" (Oregon) or "work" (Kansas).

Checking each insurer's policy may seem time-consuming. But, with 69210 ranking in the top-50 most performed FP procedures, your practice can't afford to miss out on allowed charges.

Action: Call your major payer's provider relations departments. Have the representative at each send you the insurer's 69210 policy, Felger says. Look at the payer's requirements and determine when you can bill 69210 for patients covered under each insurer.