Wiki Ear lavage and E/M payment

[mgarcia400]

Hello all, I work for a Family Practice and have been having trouble getting E/M visits as well ear lavage 69209 both paid. I submitted a claim as follows:

1. H61.23 Bilateral Impacted Cerumen

99213-25 Linked to 1
69209- 50 linked to 1

Blue Care Network paid 69209 (a very small amount) but not 99213 stating "our clinical editing rules define this service as incidental to a more inclusive service"

Can anyone further explain why E/M visits are not separately payable? Why pay the significantly lesser charge vs. the office visit?

Any insight is appreciated

I've also had previous claim when office visit was paid but not ear lavage when there were multiple dx on the claim, stating it was a surgical global package.

Requesting help with the guidelines!

 

[sls314]

Hello all, I work for a Family Practice and have been having trouble getting E/M visits as well ear lavage 69209 both paid. I submitted a claim as follows:

1. H61.23 Bilateral Impacted Cerumen

99213-25 Linked to 1
69209- 50 linked to 1

Blue Care Network paid 69209 (a very small amount) but not 99213 stating "our clinical editing rules define this service as incidental to a more inclusive service"

Can anyone further explain why E/M visits are not separately payable? Why pay the significantly lesser charge vs. the office visit?

Any insight is appreciated

I've also had previous claim when office visit was paid but not ear lavage when there were multiple dx on the claim, stating it was a surgical global package.

Requesting help with the guidelines!

Many payers are starting to automatically deny Modifier-25 claims because historically they've been abused by many providers. If there was a separately identifiable office visit, I'd send records to BCN to prove that and get the claim reconsidered.

The 69209 is the Column 1 Code in the NCCI PTP edit, so that's why that's the code that paid.