Pediatric Coding Alert

When a pediatrician sees a patient and determines that its necessary to remove impacted ear wax, there are usually two codes used: 69210, for removal of impacted cerumen, and an office-visit code. To get paid for both, its necessary to affix the -25 modifier to the office-visit code. However, there can be problems getting paid for both, because some insurance companies are refusing to recognize the -25 modifier.

The case is explained succinctly by Heather Elsesser, accounts manager for Candlewood Valley Pediatrics, a three-pediatrician practice in New Milford, CT. Were having problems being reimbursed for modifier 25 visits, Elsesser writes. The example she uses is a visit for removal of impacted cerumen, which, in her office, is usually CPT 99213 . Our office visit charge is $43, she writes. Our charge for 69210 is $15. Were finding were only being reimbursed $15, and the $43 needs to be adjusted. This is happening mostly with one carrier. Some other carriers are paying the office-visit code, and not the cerumen removal. Are we coding this correctly?

The answer is yes, you are coding it correctly.

This is what modifier -25 is for, according to CPT:
Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service.

But, to get reimbursed, you may have to code differently. We received this advice from two billing experts who have had a similar experience.

1. Use the -25 modifier, but look for additional diagnoses, and use them first. This is the best way that Judy Williams, coder for Daniel L. Thornton, MD, FAAP of Vero Beach, FL, has dealt with the problem of an office visit and cerumen removal. A lot of times the doctor has found more than one diagnosis, says Williams. There may be an upper respiratory infection, or otitis media. If there is more than one diagnosis (besides impacted cerumen), then she uses the other diagnoses in the top slots on the claim form. I put the -25 modifier on the office visit, but list the impacted cerumen diagnosis last, she says. What if there are no other diagnoses? Then we dont bill for the cerumen removal at all, says Williams. At least we get paid for the office visit that way. The problem, as Williams puts it, is that some insurance carriers just pay the lower charges. To get around this, you have to be smart. It may be tricky, but its not fraud, says Williams.

2. Forget the -25 modifier, and upcode the office visit. Ive tried the -25 modifier in this situation, and it doesnt work, says Carmen Cortes, billing coordinator for Island Coast Pediatrics, a six-pediatrician practice in Cape Coral, FL. So, what we do is increase the level of the office visit, and we increase the documentation as well. Increasing the documentation is essential, says Cortes. The doctor has to put it all in the notes: the history of the complaint, the fact that he saw the cerumen, that he had to remove it, and the recommendations and instructions he gave to the parent, she notes. It is important to document that the cerumen was removed, even though neither the 69210 or the -25 modifier is used. We dont bill for the cerumen removal at all, but we do document that we did it (in order to justify the higher level office visit), explains Cortes. If you find you have little success using both the office-visit and the cerumen-removal codes, then upcoding may be a possibility, especially if the cerumen removal resulted in the physician spending, say, half an hour with the patient (this situation could justify upcoding to a 99214 from 99213).

3. If there is a definitive diagnosis, such as otitis, place that ICD-9 code on the office visit. Then put the diagnosis code for cerumen removal (380.4) alone with the cerumen removal code (69210).

4. Bear in mind that if you charge a 69210 and an office visit, you will probably be charging well over $100. It is not recommended that you use 69210 for a swipe or two with the curette. If, however, irrigation is necessary, this code is definitely appropriate.

If you want to take the high road and demand that your carrier recognize modifier -25, you are certainly within your rights. The above situation is exactly what this modifier is for. After all, a mother doesnt bring her child to a pediatrician and say, Here, remove my childs cerumen. The pediatrician has to decide whether it has to be done, how to do it, whether there is an infection, and whether the ear canal should be irrigated. And thats only the ear. There may be another medical condition, and the pediatrician needs to examine the rest of the child as well. An office visit certainly is called for.