Otolaryngology Coding Alert

Question: When a Medicare patient presents to our office with a chief complaint of "hearing loss" and a cerumen impaction, the otolaryngologist removes the impaction under microscopic visualization. To detect any potential middle-ear contributions, the physician orders in-office tympanometry.
 I bill the services as 9921x, 69210 and 92567. Medicare, however, rejects 9921x and 69210, stating "payment adjusted because this procedure/service is not paid separately."

How do you recommend we submit charges for these services?


Ohio Subscriber
Answer: Depending on the impaction specifics of each case, you should file these claims using a different cerumen removal code. You can also combat denials with modifier 25 on the office visit code and separate E/M and test diagnoses.

To receive payment for a same-day cerumen removal and audiological test (such as 92567, Tympanometry [impedance testing]), you will have to report G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing) instead of 69210 (Removal impacted cerumen [separate procedure], one or both ears). Current CMS policy considers cerumen removal part of audiologic diagnostic testing and will not separately pay 69210, according to the 2005 Medicare Fee Schedule and Hospital Outpatient Prospective Payment System for Audiologists. In 2003, CMS introduced the HCPCS code to reimburse doctors for complicated impacted cerumen removal that requires a physician's skill.

Be careful: You should only use G0268 when the otolaryngologist performs cerumen removal prior to same-day audiological testing. Your otolaryngologist should not routinely perform this service. Rather, the cerumen removal must be too complicated for the audiologist to perform - in other words, it must be truly impacted - so the otolaryngologist must perform the procedure.

You should, however, appeal the office visit denials. Before doing so, check that you reported 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Modifier 25 tells the carrier that the otolaryngologist performed a significant, separate office service from the audiological testing.

Your ICD-9 coding should demonstrate that the E/M is separate from the tympanometry. For the office visit diagnosis, you should use the patient's complaint of hearing loss (388.40, Abnormal auditory perception, unspecified). You would then link the audiologist's findings, such as sensorineural hearing loss (389.1x), to the test.