Coding Cerumen Removal --> RE: moonlighting

[Guest guest]

OK, first, I am actually there to evaluate people for hearing complaints prior to the audiologist coming and checking hearing. In the nursing home setting it is very common that the problem with hearing is actually very impressive cerumen impactions (I'm talking the size of cat poop, sorry for the vulgarity). This is not just a little cerumen scooping. Sometimes the patient can't hear because they have a huge tm perforation etc... I bill for a consult for hearing loss and another procedure code and icd code for cerumen IF they have it. Medicare pays for both in this instance. I know in the office I have difficulty getting payment. I have no idea why this is different. KrisWondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.

[Guest guest]

I've always found coding for wax removal confusing -- shouldn't this be fairly straight forward?

Technically, my understanding was that it was mainly paid if it was the main reason for the visit -- not that the patient was there for an otitis and you had to move a little wax out of the way to see the TM.

See the guidelines below for more info.

Even after reading the info, I'm still confused of whether I can do much outside of...

Patient ONLY presents for SYMPTOMATIC ear wax

and

I use a loop (not solvents) to get the wax out.

http://www.aafp.org/fpm/20050200/coding.html

Coding cerumen removal

Q Recently, I was told that the appropriate use of CPT code 69210, "Removal impacted cerumen (separate procedure), one or both ears," requires direct visualization by the physician and removal using suction, a cerumen spoon or delicate forceps. However, my understanding of 69210 has always been more liberal than this, including removal using irrigation or chemical solvents that may be done by a physician or by ancillary staff incident-to a physician's service. Which is the correct interpretation of this code?

A It depends on the payer. Because CPT does not specify what the term "removal" refers to with this code, removal by any means would qualify from a CPT perspective. Assuming Medicare's "incident-to" rules are met, you should also be able to code this as incident-to a physician's service in some cases. (For more information on "incident-to" reimbursement, see "The Ins and Outs of "Incident-To" Reimbursement," FPM, November/December 2001, page 23.)

However, according to CMS, payment for cerumen removal is made only when the following criteria are met:

1. The service is the sole reason for the patient encounter;

2. The service is personally performed by a physician or non-physician (NP, PA, CNS);

3. The service is provided to a patient who is symptomatic;

4. The documentation illustrates significant time and effort spent performing the service.

CMS also defines routine cerumen removal as the use of softening drops, cotton swaps and/or cerumen spoon and is not paid separately since it is considered incidental to the office visit.

These criteria may also be true for some commercial payers. Check with your individual payers to determine their policies.

http://medicaleconomics.modernmedicine.com/memag/Medical+Practice+Management:+Coding/Coding-Consult/ArticleStandard/Article/detail/108609

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July 9, 2004

Coding Consult

• If you use a syringe or water pick, report 69210.

• Some carriers accept 69210 only for manual disimpaction under binocular magnification.

• Incident-to billing may pay for NP or PA services, but not for those of an RN or MA.

To assign 69210 (removal of impacted cerumen [separate procedure], one or both ears) and get paid what you deserve, you have to first be certain the earwax was truly impacted. You must then be sure the circumstances allow you to code separately for the procedure and an office visit.

Code 69210 describes manual disimpaction, which requires skill. Under direct visualization, the physician removes impacted cerumen using suction, a cerumen spoon, or delicate forceps. For example, you may view the patient's ear using binocular magnification and grasp the cerumen plug with forceps. If no infection is present, the ear canal can then be irrigated.

"Or if you used a syringe or water pick, report 69210," says Betty Mehlenbeck, a coding and compliance auditor at HealthCare Network Associates in Springfield, IL. But if you use a simple instrument such as a curette, and the cerumen comes out easily, you should include your services in whatever level of E & M code is appropriate (99201-99205 or 99211-99215). Although your carrier may not require you to use a specific instrument, to use 69210 your work must be more intensive and time-consuming than a simple earwax removal.

"We've had no problems with private payers or Medicare when billing this way," Mehlenbeck adds. But your Medicare or private carrier may have different guidelines for reporting impacted cerumen removal. For instance, First Coast Service Options, Florida's Medicare carrier, will accept 69210 only when the physician uses manual disimpaction under binocular magnification to remove the earwax. Using this method, the physician takes out the cerumen with forceps, suction, or a right-angle hook.

On the other hand, HGSAdministrators, Pennsylvania's Medicare carrier, defines impacted cerumen removal as "the extraction of hardened or accumulated cerumen from the external auditory canal by mechanical means, such as irrigation or debridement."

Medicare includes payment for binocular microscopy (92504, binocular microscopy [separate diagnostic procedure]), with 69210, so even if you use binocular microscopy, report only 69210.

Use an E & M code for lavage and solvents. Insurers will likely deny your 69210 claims if you report the code when you use cotton swabs or chemical solvents for cerumen removal.

Be sure you link 380.4 (impacted cerumen) to 69210 to support medical necessity. Most private and Medicare insurers will not accept any other ICD-9-CM codes, even if the codes describe a hearing-related problem. For example, you shouldn't use 389.x (hearing loss) or 381.81 (dysfunction of eustachian tube).

Medicare pays about $48 for 69210, according to national averages. Your reimbursement may be more or less, depending on your locality and payer. Report 69210 only once per session, even if you work on both ears. []

Incident-to requirements

You may report 69210 when a nonphysician practitioner such as a nurse practitioner or physician assistant removes impacted earwax as long as your Medicare or private carrier allows incident-to billing. Some don't.

First Coast Service Options, for instance, pays only for a physician's cerumen-removal services. When a nonphysician practitioner, nurse, or medical assistant performs the work, the carrier considers the removal a part of the E & M service.

If a carrier does allow incident-to billing, it may pay for the services of a nurse practitioner or physician assistant, but not for those of a registered nurse or medical assistant. For example, Noridian Administrative Services, a Medicare carrier, pays for 69210 only if the physician, nurse practitioner, or physician assistant performs the work.

But however your Medicare or private payer allows incident-to billing for impacted cerumen removal, remember: You must directly supervise the procedure and initiate treatment. For instance: A patient presents with hearing loss (389.x). Following the examination, you schedule the patient to return in a few days for cerumen removal. When the patient returns, the physician assistant performs the procedure under your supervision.

"Medicare requires that a physician write the initial order and follow up with the patient at regular intervals," says Marie Felger, a coding consultant in South Bend, IN.

If you yourself don't see the patient, and a nurse or PA cares for the patient, report a nurse visit (99211, office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician, typically 5 minutes are spent performing or supervising these services) for the service. []

Modifier -25 for separate visits

Say a patient comes to the office with vertigo (780.4, dizziness and giddiness), during the course of your exam, you discover impacted earwax, and decide to perform cerumen removal. Can you report both 69210 and an E & M code?

Yes, as long as the documentation shows that the E & M service was separate and identifiable, experts say. You should document that you originally saw the patient for a reason other than cerumen removal—in this case, vertigo—and attach modifier –25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E & M code (for example, 99212, office or other outpatient visit . . . established patient . . .). Link 780.4 to the E & M code. Then you could assign 69210 for the cerumen removal, using ICD-9-CM code 380.4. Linking separate ICD-9-CM codes supports your claim that you provided separate, identifiable services.

Coding Consult: Cerumen removal. Medical Economics Jul. 9, 2004;81:24.

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Locke, MD

From: [mailto: ] On Behalf Of Lynette IlesSent: Saturday, May 17, 2008 8:19 AMTo: Subject: Re: moonlighting

How do you code/charge for this?Lynette I Iles MD 301 South Iowa Ste 2Washington IA 52353 Flexible Family Care'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.