Question Highmark BS and CPT 69210 denials

cwater

Networker
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Hello,

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.

Thanks,

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Camille Waterhouse, CPC
Pinnacle ENT Alliance
 

babybiv

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McDonald, PA
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Camille

Did you get a response from anyone? I have having this same problem and cannot get a answer from insurance.
The rep could not even tell me what RP-041 meant.

Lynn Brockman, CPC, CPB
 

DeBillingTater

Contributor
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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.
 

misty2406

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Our Highmark (PA) provider rep just told us yesterday that they will not pay 69210 ever. They will either deny it as included with an e/m on the same day, or they will deny it when it is billed alone. She said we could bill an e/m if documentation supports it, but we are struggling with the medical necessity portion of the e/m when the patient strictly came in for cerumen removal. This started affecting our claims in December 2018.
 

RDK720

Networker
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Our Highmark (PA) provider rep just told us yesterday that they will not pay 69210 ever. They will either deny it as included with an e/m on the same day, or they will deny it when it is billed alone. She said we could bill an e/m if documentation supports it, but we are struggling with the medical necessity portion of the e/m when the patient strictly came in for cerumen removal. This started affecting our claims in December 2018.
Hi. Regular Cerumen Removal is considered incidental to the E&M. The medical record needs to include "Impacted" and "Removed with Tools/Forceps" for 69210 or "Impacted" "Lavage/Irrigated" for 69209.
 

misty2406

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I understand that CPT 69120 is considered incidental to the E&M. The problem is if we bill CPT 69210 as the only code, Highmark no longer covers it.

I also got clarification from our rep today that they are going by the claim process date, not the date of service. So pretty much anything processed after December 2018 will be affected.
 

Megan27

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Hi, I am curious if you are now putting these to E/M codes. My office is telling me that I should be using E/M codes to bill out the 69210. Most of the documentation says that they used irrigation/lavage (69209) along with the tools. I was thinking that 69209 would be more clear, but they are telling me no. Does anyone have an opinion on that?
 
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