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Question Highmark BS and CPT 69210 denials


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We are being denied by Highmark BS for the procedure code 69210. The denials have been for claims with and without an office visit. The claims submitted with an office visit have been submitted with the appropriate modifier (25). We have not seen any rejections for cerumen removal when submitted with a hearing test but the code submitted for cerumen removal on the same day as an audiological test is G0268 not 69210.

We have appealed the claims with Highmark BS and have not had any overturned. The appeal responses point us to policy RP-041.
The CPT 69210 is being considered included in the global allowance for other services not specified. The CPT 69210 will be rejected and is non-billable to the member.

Has anyone had success in having the denied claim(s) overturned? If yes, please share your process. If no, how are you handling the denied claims?

I look forward to your responses.


Camille Waterhouse, CPC
Pinnacle ENT Alliance


Best answers
Could very well be a contracting issue and that's just one of the codes not covered under your contract. We bill 69210 with no problems with diagnoses H61.20-H61.23. But it is listed in our fee schedules in the contracts. I would check to see if that certain procedure is listed in your fee schedule and appeal using that.