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Incident to issues

  1. #1
    Greeley, Colorado
    Question Incident to issues
    Medical Coding Books
    I have a PA that works for an ENT.
    1 - She is coding 99213 instead of 69210 when that is what she actually did. I know this is wrong, just need some reinforcement to provide to her supervisor.

    2 - In relation to that, if a patient comes in for 69210 routinely (every 6 months and possibly more frequenty), Medicare states that the MD must have active participation in the care - can anyone help me with a recommendation as to how often the patient should see the MD for "active participation"?

    3 - Would you consider "wax rebuilding" on a regular basis a new problem each time or the same problem? (As in the patient just has excessive ear wax and has to have it removed on a regulare basis).

    All feedback is much appreciated!!
    Lisa Bledsoe, CPC, CPMA

  2. #2
    Columbia, MO
    you may not substitute codes if the 69210 is what the patient came for and was performed tben that is what must be coded . To do code otherwise could be construed as over or under coding which is also fraud. As for the recurrent ear wax buidlup, I see this the same as a recurrent UTI and each occurance is a new problem

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Evansville Indiana
    Default ear
    I would agree that it is a new problem, but I personally would put it in the self-limited category.

  4. #4
    Greeley, Colorado
    Thanks Ladies! I agree with both of you; this PA is arguing about the issues. Does anyone have information on what "active participation" the MD needs to provide? I cannot find a specific time frame from CMS. I think I once heard every 3rd visit, but not sure where I heard that...
    Lisa Bledsoe, CPC, CPMA

  5. #5
    Lightbulb Cerumen Removal vs Ear Lavage
    This is from CPT Assistant, July 2005 Page: 14 Category: Coding Consultation.

    In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), we present the following discussion which provides some typical coding scenarios with regard to the appropriate use and application of CPT codes related to ear wax removal:

    1. The patient presents to the office for the removal of "ear wax" by the nurse via irrigation or lavage.

    2. The patient presents to the office for the removal of "ear wax" by the primary care physician via irrigation or lavage.

    3. The patient presents to the office for "ear wax" removal as the presenting complaint. This is described as impacted cerumen because it completely covers the eardrum and the patient has hearing loss. The impacted cerumen is removed by the primary care physician or otolaryngologist with magnification provided by an otoscope or operating microscope and instruments such as wax curettes, forceps, and suction.


    Are these procedures appropriately reported with CPT code 69210, Removal impacted cerumen (separate procedure), one or both ears?

    AMA Comment:

    A major element in determining whether code 69210 should be reported is understanding the definition of impacted cerumen. By definition of the AAO-HNS,

    "If any one or more of the following are present, cerumen should be considered 'impacted' clinically:

    Ÿ Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.

    Ÿ Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.

    Ÿ Inflammatory considerations: Associated with foul odor, infection, or dermatitis.

    Ÿ Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills."

    Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting of CPT code 69210. Rather, that work would appropriately be captured by an evaluation and management (E/M) code regardless of how it is removed.

    If, however, the wax is truly impacted, then its removal should be reported with 69210 if performed by a physician using at minimum an otoscope and instruments such as wax curettes or, in the case of many otolaryngologists, with an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angles). Accompanying documentation should indicate the time, effort, and equipment required to provide the service.

    Add-on code 69990, Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure), should not be reported if the operating microscope is used for cerumen removal. In this later instance, however, code 92504, Binocular microscopy (separate diagnostic procedure), may be reported.

    Therefore, based on this information, scenarios 1 and 2 would not be reported with code 69210. These scenarios would be captured by the appropriate E/M code. Scenario 3, however, should be reported with code 69210 because both criteria were met; the patient had cerumen impaction and the removal required physician work using at least an otoscope and instrumentation rather than simple lavage.

    In the past, code 69210 has been covered when billed with modifier -59 appended to the procedure code, but that no longer will be covered.

    Coverage under code 69210 is covered only when the cerumen is impacted. If the cerumen is not impacted, removal by lavage will be covered as part of an evaluation and management (E/M) service.

    CPT Assistant © Copyright 1990 - 2008 American Medical Association. All Rights Reserved

  6. #6
    Greeley, Colorado
    Thanks BJ - but I still need some help with the "active participation"...any advice or resources?
    Lisa Bledsoe, CPC, CPMA

  7. #7
    Default CMS has no definition for "active participation"
    You just gotta love them for that...

    Some of the carriers do have definitions though, thats where the every 3rd visit came from, I'm not sure but I want to say that is a Trailblazer thing.

    The OIG has made comments on some of their audits regarding things they felt didn't qualify but as yet no actual definition has been released by either CMS or the OIG. You would think with the extra attention they are putting on incident to they would get around to defining it.

    Look thru your carriers site and see if you can find anything from them. If not I would suggest you come up with some type of office policy to cover what your provider feels is "active" that way you can be consistent.

    Laura, CPC, CPMA, CEMC

  8. #8
    Greeley, Colorado
    Thanks Laura. Yes, it is very helpful when they leave those gray areas out there for us to try to figure out! Our carrier is actually TrailBlazer, so I'll look on their website a little more to see if I can come up with anything.
    Lisa Bledsoe, CPC, CPMA

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