How to Get Paid for Cerumen Removal and an Office Visit on Same Day
Published on Fri Oct 01, 1999
Removing impacted cerumen (69210) is a relatively common procedure in pediatrics, but understanding how to code for it is unclear. The big question is: Can you bill for the procedure codes for removing the cerumen and an office visit?
Debra Bales, billing representative for Orange-Irvine Doctors of Children in Orange, CA, writes to ask how to handle the typical scenario, in which a child has URI symptoms, the pediatrician looks in the ear to see if its infected and determines there is impacted cerumen, and performs an ear lavage to remove the wax.
This is another case in which some carriers will pay, and some wont, which could result in payment received from all carriers if you pursue the subject of payment.
1. Selective billing. Take the situation at Jacksonville Pediatrics where billing manager Kim Taylor charges insurance companies that will pay for the office visit as well as CPT 69210 , and doesnt bill those that dont. We used to file all the codes, but the pediatricians dont like to see a balance hanging, she says. But from an accounting aspect, it would be better to file it and know we were doing the work. In many cases, it would not be right to bill differently depending on carrier. But in fact, many carriers have specific rules regarding 69210 and office visits. Thats why fees for 69210 vary from $15 to $200, according to HealthCare Consultants of America 1999 Physicians Fee & Coding Guide. (The average range is $45 to $57, according to the guide.) Part of the variation relates to whether the physician routinely bills an office visit with the procedure or not, the guide states.
Tip: The office should bill differently only when required by contract. And if your contract says the company will pay only for the procedure, and not the office visitrenegotiate!
2. Modifier -25. Many coders agree that it would be best to bill for an office visit and the cerumen removal, regardless of whether the carrier will payat least theoretically. But in practice, if the carrier wont pay, how can you get reimbursed for both services? After all, the child didnt walk in and announce, I have impacted cerumen, please remove it. The pediatrician had to conduct a history and physical first to determine what was happening (fever, cold, etc.)thats the office visit. The cerumen removal is a procedure that is separate from the office visit.
Technically, you should use modifier -25 on the office visit to designate that it is a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Note that you do not need a [...]
