Practice Management Alert

Impacted cerumen removal is a fairly straightforward procedure, but billing for the procedure is not always so simple.

The problem: Most payers, including Medicare,consider 69210 (Removal impacted cerumen [separate procedure], one or both ears) to be a minor procedure. But unlike with other minor procedures, they only pay for an E/M service as well as the removal of the impacted cerumen when you have two unrelated diagnoses -- one for the E/M service and 380.4 (Impacted cerumen) for the removal of impacted cerumen.

The solution: By learning just three simple steps, you can ensure your physician is getting the reimbursement he deserves for this common procedure.

A patient does not usually present for impacted cerumen alone. Another condition, such as ear pain or hearing loss, will usually prompt the visit. When your physician documents that additional diagnosis, you can report two codes to represent the work for both services, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls,N.J., and senior coder and auditor for The Coding Network.

First, you would report one code for the significantly separately identifiable E/M service, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...). Then, you could report 69210 for the impacted cerumen removal. Documentation must support the medical necessity basedon symptoms and diagnosis; otherwise, the insurer will bundle the E/M service into 69210.

Note: CMS has a list of conditions for allowing you to separately bill an E/M code and 69210. They will allow separate billing when all of the following are met: The nature of the E/M is for anything other than cerumen removal

During an unrelated encounter, the physician observes impacted cerumen or the patient complains about his ears Otoscopic examination of the tympanic membrane TM is not possible due to impaction

Removal of the impaction requires the expertise of the physician and is personally performed by him The procedure requires a significant amount of time and is clearly documented as such.

Crucial point: "Removal of impacted cerumen is not an ear wash; it takes instruments and the skills of the physician," Cobuzzi says.

To receive separate reimbursement for the E/M service -- and to code properly -- you will need a modifier.Append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code.

Tip: Always provide separate documentation for the impacted cerumen removal procedure "so that you are demonstrating that the E/M is a separate procedure from the removal of the impacted cerumen," Cobuzzi says. Do not bury your procedure note in the E/M note.Proper documentation of the patient's complaint, his medical history, an examination beyond the ear, and a medical decision to remove the cerumen as well as a treatment plan for the second diagnosis, can legitimize a separate E/M procedure and thus support the use of the 25 modifier.

Some payers do not consider 69210 to be inclusive or mutually exclusive of an E/M procedure. Others have strict guidelines for how the physician executes the procedure, or they put a cap on how often the service is paid for. Check your payer's regulations on cerumen removal before billing this service.

Take note: Medicare does not pay for an audiologistto remove impacted cerumen. Therefore, if you are billing Medicare you need to send confirmation that the impacted cerumen removal on the day of audiological services was performed by the physician.

The catch: Medicare will not pay for 69210 and an audiology service on the same day. They require the recoding to G0268 (Removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing service as audiologic function testing) indicating that a physician performed the removal on the day of audiology services. Some private payers also pay this G code.