Otolaryngology Coding Alert

Question: I’m getting denials from nearly all carriers when billing out for 69210. These are billed out with an E/M visit with modifier 25 appended. Depending on whether it’s bilateral or unilateral, we append modifier 50, or LT/RT. We get two different types of denials — one for bundling and one for an incorrect modifier. What am I doing wrong?

Utah Subscriber

Answer: There are two separate issues to address with your claims. First, you should not be submitting 69210 (Removal impacted cerumen requiring instrumentation, unilateral) with any modifier for Medicare. Despite the unilateral code description, Medicare will deny your claim if you append modifiers LT (Left Side), RT (Right Side), or 50 (Bilateral Procedure). Additionally, you should not submit 69210 as more than one unit. The service should be billed the same whether the physician performs the cerumen removal unilaterally or bilaterally.

You’ll also want to make sure you are using H61.2X (Impacted cerumen) diagnosis codes accordingly depending on the laterality or bilaterally of the impacted cerumen. If you are reporting an E/M visit with modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service), it may be necessary to show that the E/M is entirely separate from the impacted cerumen. This means that you must bill the E/M visit with a separate diagnosis code from the impacted cerumen diagnosis.

Keep in mind that there are some instances where you may opt to report the signs and symptoms with the E/M visit despite a more definitive diagnosis being available. ICD-10-CM guidelines advise that you report the definitive diagnosis over the signs and symptoms, but this isn’t always practical when considering whether an E/M service will be reimbursed alongside a same-day procedure.

One last bit of information to consider is that some commercial payer guidelines differ from that of Medicare. If you are receiving a denial from a payer other than Medicare, it may be worth your time to inquire about their 69210 billing policy.

For example: You will want to find out how your non-Medicare payers process 69210 in terms of bilateral services. Every payer can have different rules as to whether they recognize the bilateral nature of the code when performed bilaterally, and each payer requires you to report bilateral differently. So, if they do recognize removal of impacted cerumen as a bilateral service, you have to know if they want bilateral services as one line as CPT^® and Medicare instructs, or if they want you to submit two lines with a 50 on the second line, or if they want two lines with the LT and RT modifiers instead of the 50 modifier. Every payer can have their own preferences and rules, unfortunately.