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Wiki Cerumen Removal - I've been struggling with billing for bot

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BABS37

BABS37

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I've been struggling with billing for both an E/M and Cerumen Removal with my providers. It's my understanding that it's basically one or the other unless the E/M identifies it's separate from the reason for the encounter. I am only billing for the Cerumen Removal when scheduled as 'Routine Ear Cleaning' as I don't feel the documentation supports both.

The question that constantly comes up is this: My provider schedules the patient three, four, or six months out for "Cerumen Removal" and then argues that I haven't seen the patient in six months so I should be able to bill for a follow up. There are no underlying conditions to substantiate an E/M being billed. Does anyone else have this problem? And, if so, how do you back yourself up?

Thank you for any thoughts!
 
You are correct, simply performing an E&M due to not seeing the patient in six months does not meet medical necessity. There must be a significant or separate service to support an E&M from a procedure on the same day.

Routine cleaning alone does not support Medicares and most carriers medical policy that the cerumen is impacted. Just a reminder that lavage is not a billable component and would be part of the E&M if no procedure was reportable.

For situations where the patient is scheduled for a minor procedure, only the procedure is reportable as long as he documentation supports the code.
 
Ok, I just want to make sure I'm ok not billing them both. Here is a sample sentence- the only thing listed in his H&P before the cerumen procedure note and in this example, the DOS is 06/12/14 and the previous DOS was 10/16/13 and said :follow up for routine ear cleaning six months.

This patient is seen for a checkup on his ears. Has a history of recurrent cerumen impactions and relatively narrow ear canals. Denies any pain or discharge but is feeling a little full.
 
Requirements for reporting 69210 with an E/M on the same DOS

When reporting an E/M visit and cerumen removal on the same date of service (DOS), the following criteria must be met: 1. The initial reason for the patient’s visit was separate from the cerumen removal. 2. Otoscopic examination of the tympanic membrane is not possible due to the impaction; 3. Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner and is personally performed by him or her; and 4. The procedure requires a significant amount of time and effort, and all of the above criteria are clearly documented in the patient’s medical record.

https://www.entnet.org/content/cpt-ent-cerumen-removal
 
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