Wiki Ear lavage 69210

[mgarcia400]

I bill for a Family Practice. I have recently been having issues getting payment for office visit 99213/14 along with ear lavage 69210. Some insurances have stated that it's global and only pay the ear lavage and not the office visit or vice versa. In the past, I've never had issues with this. Seems to be more recent with commercial and Medicare advantage plans.

And example of a recent claim was:
DX H61.23 Bilateral impacted cerumen

CPT: 99213- 25
69210

The ear lavage was paid, but the office visit was not even with the modifier 25.

Any insight as to why this is happening would be greatly appreciated.

I have called insurances about it and they all seem to have a different response.

Thanks

 

[thomas7331]

First of all, ear lavage is 69209, not 69210, so you may want to double-check your coding on this.

Regarding the modifier 25, if the modifier is truly supported by documentation then it should be paid. Unfortunately, the modifier is widely abused by providers, and I've heard that many payers have just made it a policy not to pay it at all, or they may only pay it in certain circumstances - only for a separate diagnosis, for example. (I usually refer to this kind of a policy as a 'guilty until proven innocent' policy.) If this is the case, the payers should be able to point you to their written policy that outlines their guidance on this - in what cases, if any, they will allow it, and what your appeal rights are if they do not. If the payer has no policy on this and the claim is correctly coded, then you should appeal the denial with notes because it should not have been denied.

 

[KGETGEN]

CPTs 69209 and 69210 are Surgical Codes.
Per the CPT Surgical Package Definition:
By their very nature, the services to any patient are variable. The CPT codes that represent a readily identifiable surgical procedure thereby include, on a procedure-by-procedure basis, a variety of services. In defining the specific services “included” in a given CPT surgical code, the following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included in addition to the operation per se:
■Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)

So if the only Dx is for the Impacted Cerumen, the E/M will deny always.