Part B Insider (Multispecialty) Coding Alert

Published on Fri Feb 07, 2014 PDF

Medicare decides not to pay for two cerumen removals in the same visit.

When  CPT^® clarified the language in  CPT^® 2014 regarding cerumen removal, it seemed like good news. But thanks to a CMS rule, that news could be turning sour.

Background:  CPT^® 2014 changed the descriptor for 69210 to “Removal of impacted cerumen requiring instrumentation, unilateral.” Therefore, most practices understood that they’d need to append a bilateral modifier (modifier 50) to 69210 when removing cerumen from both ears. Why? Although the descriptor for this code used to say “one or both ears,” it now specifically states “unilateral.”

Although this seemed like it might help open the door to bilateral reimbursement, the reality could be the opposite for Part B practices. The 2014 Medicare Physician Fee Schedule Final Rule states that CMS will “allow only one unit of  CPT^® 69210 to be billed when furnished bilaterally,” citing the agency’s belief that both ears would be addressed most of the time “as the physiologic processes that create cerumen impaction likely would affect  both ears.”

In other words, CMS believes that doctors will be removing cerumen from both ears more often than not, and claims that the code is therefore already valued for addressing both ears.

 CPT® Clashes With CMS

Needless to say, this flies in the face of  CPT^® guidance, which creates a quandary for many practices that were hoping to increase reimbursement after the latest  CPT^® revisions. The American Academy of Otolaryngology has already stated that it has contacted CMS to resolve the issue. “We are seeking clarification from CMS regarding how to code and bill for this service given that the  CPT^® code descriptor and code book are not consistent with the policy CMS has stated they will implement,” the Academy says on its website.

Keep an eye on the Insider for more on this topic as developments occur.