Primary Care Coding Alert

Question: A patient came in complaining of congestion in his ear. After examining the patient and discovering impacted cerumen in his ear, the FP removed the cerumen. I coded 99212 for the office visit and 69210 with modifier -25 for the ear irrigation. The insurance company only paid for the E/M service, saying that the cerumen removal was part of the office visit. How can we get paid for this obviously separate procedure? Florida Subscriber Answer: Coding for impacted cerumen removal is a thorny issue for many family practices, partly due to a misinterpreted Medicare policy bulletin. Many coders thought the policy meant that Medicare would never reimburse an office visit and cerumen removal on the same day, but this is not the case. Medicare will pay for both, as will many private payers, only when specific criteria are met.

The key to getting paid for both lies in the reason the patient comes to the office. If he or she comes in specifically for cerumen removal, you can only bill the 69210 (Removal impacted cerumen [separate procedure], one or both ears). However, if the patient comes in for a different problem and the physician finds impacted cerumen and removes it, you can code for the office visit and 69210, as long as you meet the following requirements:

Impacted cerumen is found. Removal is deemed medically necessary. The cerumen is removed in a procedure performed or supervised by the physician or nonphysician practitioner. Removal requires significant effort by the provider. Your best bet for reimbursement is to have two different diagnosis codes. In your case, you could link an appropriate diagnosis code to describe ear congestion (such as 381.81, Dysfunction of Eustachian tube) to the 99212 (Office or other outpatient visit for the evaluation and management of an established patient ) and combine 380.4 (Impacted cerumen) with 69210. Make sure you attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. Also, note that 380.4 is the only diagnosis code Medicare will accept with 69210, and most private payers follow suit.

You have a better chance of reimbursement if your diagnosis code for the office visit is completely different from that of the cerumen removal. For example, if your patient presents with flu-like symptoms and you are able to link 487.1 (Influenza with other respiratory manifestations) to the E/M code, most payers will clearly see the difference between the two services and will reimburse them separately. But, in most cases, you will be using a diagnosis code from the 380-389 series (Diseases of the ear and mastoid process) with the E/M, [...]