Primary Care Coding Alert

Are your billing 69210 impose additional restrictions. CPT when nurse removes impacted cerumen? With incident-to, you probably can.

You may report 69210 when staff remove impacted cerumen, as long as a payer doesn't stipulate that your family physician (FP) must perform the procedure.

If a nonphysician performs cerumen removal and  meets the insurer's requirements, you would bill 69210 under the physician's personal identification number (PIN) or incident-to the FP.

Insurers vary on their incident-to guidelines. Private insurers usually impose fewer restrictions, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, health information management certificate programs coordinator at Clarkson College in Omaha, Neb. Before you bill Medicare, you must meet these three requirements:

National Heritage Insurance Company, North California's local Medicare carrier, allows a nurse or medical assistant (MA) to bill 69210, says Neil Knutsen, CPC, senior analyst at California's Palo Alto Medical Foundation reimbursement department, which serves 50 family physicians in four cities. The only requirement is that the FP must provide direct supervision.

Translation: The FP must be in the office suite. If staff remove impacted wax and the FP provides direct supervision, you can bill 69210 under the physician's PIN, says Marie Felger, CPC, Family Practice Management editorial advisory board member.

2. The FP must initiate treatment. Medicare requires that a physician write the initial order and follow up with the patient at regular intervals, Felger says. Even if your FP doesn't see the patient at each cerumem removal visit, you may bill 69210 when a nurse performs the procedure. Typically, the FP will check the nurse's work, she adds.

Strategy: A standing cerumen removal order in the patient's FP writes, "Patient has recurring impacted cerumen problem," and tells the patient to come in and see his nurse whenever he thinks he needs his ears cleaned out, you could bill 69210 incident-to the physician. A plan of care is in place, which the nurse is following, Felger says.

3. Your carrier permits nonphysicians to remove cerumen. Some insurers specifically exclude nonphysicians from performing 69210. For instance, HGS Administrators, Pennysylvania's Medicare Part B carrier, stipulates, "Removal of impacted cerumen performed by someone other than the physician or nonphysician provider is not billable." That means a nurse or office technician may not report 69210 incident-to the physician.

But a nonphysician practitioner, such as a nurse practitioner, may bill the procedure under her own PIN or incident-to the FP. Billing depends on whether the procedure meets the incident-to requirements outlined above.