Billing CPT 99392 with 69210 & 99213 with 81002 and family practioner billing 95811

procedure code and description

69210- Removal impacted cerumen requiring instrumentation, unilateral - average fee payment - $90 - $100




99392 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years)


Can you file CPT code 99392 with CPT 69210

Ans : Yes. You can.

Note : CPT 69210 will not be separately reimbursed when submitted with CPT 99392. When an evaluation and management service is billed with CPT code 69210, the service with the highest RVU will be paid. An example of billing a procedure in addition to a well visit is cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears). A 4-year-old comes in for a preventive medicine services visit. The mother mentions that her child does not seem to hear well. The doctor detects impacted cerumen and removes it, billing 69210. Although modifier -25 is not technically required because 69210 is not a starred procedure and not bundled with 99392 ( early childhood [age 1 through 4 years]), you should still use the modifier. Payers may require it to differentiate between the well visit and the procedure, Callaway says. Use diagnosis code V20.2 for 99392-25, and 380.4 (Impacted cerumen) for 69210.

Current procedural terminology (CPT) 69210

he billing procedure for ear lavage (CPT 69210) with Blue Cross and Blue Shield of Kansas (BCBSKS) has changed since the last notification in the Blue Shield Report S-14-00. BCBSKS policy continues to consider 69210 as content of an evaluation and management (E/M) service when both are billed on the same day unless it is noted as a distinct procedure, not related to the E/M service.

In order to receive reimbursement for 69210 as a distinct procedure from an E/M service provided on the same day, you must bill this code with modifier 22, accompanied by the pertinent, supportive documentation. The medical record must document (1) the use of water irrigation or extensive curettage, (2) a minimum of 20 minutes devoted to the performance of the procedure, and may include other techniques as part of cleaning such as:

· cerumenolytic agents,

· intermittent drying, and

· re-examination during cleaning.

BCBSKS individual consideration of additional reimbursement for this service will be based upon the above criteria.


The new description of CPT code 69210 is as follows:

Removal, impacted cerumen requiring instrumentation, unilateral What does this mean* Here are a few criteria that need to be met when reporting CPT code 69210:

• The procedure must be performed by a physician or other qualified health care professional (i.e. – NP, PA, CNS)

• The cerumen impaction must require the use of instrumentation such as a curette, ear spoon or forceps

CPT code 69210 may no longer be reported for:

• Removal of cerumen that is not impacted

• Removal of cerumen using irrigation or lavage

• Removal of cerumen using manual techniques other than instrumentation (i.e. - cotton swabs)

• Removal of cerumen performed by a nurse, medical assistant or technician Removal of cerumen that does not meet the criteria required under the new definition is considered to be included in the evaluation and management service rendered.

CPT also defines CPT code 69210 as a “unilateral” procedure that should be reported using a -50 modifier (bilateral procedure) if performed on both ears.

Seems pretty straightforward, doesn’t it* Well, “hear” is the issue. The Centers for Medicare and Medicaid (CMS) published information in the 2014 OPPS Final Rule indicating that they will not accept CPT code 69210 with a -50 modifier. Medicare reimbursement for 69210 will only be made for one unit of service, regardless of whether one or two ears are involved.

UCare will follow Medicare guidelines and will process claims for CPT code 69210 based on a unit of one. Claims submitted with a -50 modifier will deny. Questions*



Indications:

The following applies to all payable cerumen disimpaction, CPT 69210 and HCPCS code G0268

Medically necessary removal of impacted cerumen requires a physician's skill when removal by an individual other than a physician or qualified non-physician practitioner poses an unacceptable risk of complications such as tympanic membrane perforation.

Cerumen removal requiring a physician’s skill may include cases where the tympanic membrane cannot be observed (e.g., total occlusion or impaction), there are overt medical contraindications such as anatomical abnormalities, surgical modifications, or risk of infection, presence of medical conditions that pose undue risk of excessive bleeding (e.g., use of anticoagulants), or the cerumen cannot be removed safely without undue risk of abrasion, laceration, or tympanic membrane perforation.

Removal of impacted cerumen is covered if it is reasonable and necessary for the diagnosis or treatment of illness or injury.

Payment is made for impacted cerumen removal requiring a physician's skill when personally performed by a physician.

Payment may be made only for: a) medically necessary removal of symptomatic impacted cerumen; b) medically necessary removal of impacted cerumen impeding the physician's ability to properly evaluate or manage other signs, symptoms or conditions (e.g., examination of the tympanic membrane in cases of otitis media); or c) medically necessary removal of impacted cerumen impeding a physician's or audiologist's ability to perform covered, medically necessary audiometry.

Payment may be made for both removal of impacted cerumen and an E/M service only if the E/M service represents a medically necessary, significant and separately identifiable service that is supported by medical record documentation.

Payment for G0268 may be made to a physician whose skill is required to remove impacted cerumen on the same date as his or her employed audiologist performs audiologic function testing.


Limitations:

Billing and reimbursement for CPT code 69210 or HCPCS code G0268 is limited to clinical circumstances where documentation supports these to be reasonable and necessary services requiring a physician's skill. The routine removal of asymptomatic, non-impacted, non-obstructive cerumen does not generally require a physician's skill and is thus not considered reasonable and necessary.

Visualization aids, such as, but not necessarily limited to binocular microscopy, are considered to be included in the reimbursement for CPT code 69210 and HCPCS code G0268 and should not be billed separately.

When the sole reason for the visit is the medically necessary removal of symptomatic impacted cerumen, an E&M service may not also be billed in addition.

An E&M service on the same day as removal of impacted cerumen may not be billed unless it represents and is documented to be a significant, separately identifiable service on the same day. 

For example:

If the patient has pain in the external ear as his/her only complaint and the removal of cerumen addresses that complaint, one should bill only for removal of the cerumen, CPT code 69210.

If the patient also has symptoms of otitis media requiring further evaluation, then it may be justified to also bill for an E&M service with modifier –25.
HCPCS code G0268 should be billed only where a physician's skill is needed to remove impacted cerumen on the same day as audiologic function testing performed by his/her employed audiologist. This code should not be used when the audiologist removes the cerumen, because removal of cerumen is considered to be part of the diagnostic testing and is not paid separately.

It is recognized that audiologists' education, experience or practice may include or require techniques of cerumen removal. However, Medicare can pay audiologists only for medically necessary diagnostic testing, which is considered to include any incidental cerumen removal by the audiologist. Medicare cannot reimburse audiologists for CPT code 69210 or HCPCS code G0268 under any circumstances.

Covered ICD code

ICD-10 CODE DESCRIPTION

H61.21 Impacted cerumen, right ear
H61.22 Impacted cerumen, left ear
H61.23 Impacted cerumen, bilateral


Question: Are all of these procedures appropriately reported with CPT code 69210, Removal impacted cerumen requiring instrumentation, unilateral?

 Answer: No. Only the third scenario listed above would be reported with CPT code 69210. A major element in determining whether code 69210 should be reported is based upon an understanding of the definition of impacted cerumen. The AAO-HNS defines cerumen as impacted if any one or more of the following conditions are present:

• Cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition;

• Extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, hearing loss, etc;

• Cerumen is associated with foul odor, infection, or dermatitis; or

• Obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician skills.


Coding Update: Auditory System (69210)

Auditory System code 69210, Removal impacted cerumen requiring instrumentation, unilateral, is revised in the CPT 2014 code set to include the use of instrumentation in the removal of impacted cerumen (ear wax) and to clarify that the procedure is unilateral. In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), this article discusses the following hree coding scenarios related to earwax removal and the appropriate CPT codes to report  once the 2014 revisions become effective:

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

2. The patient presents to the office for the removal of earwax by a physician (any specialty) via irrigation or lavage.

3. The patient presents to the office for earwax removal, which requires magnification provided by an otoscope or operating microscope, and instruments such as wax curettes, forceps, or suction by the primary care physician or otolaryngologist. This latter situation occurs most commonly when impacted cerumen completely covers the eardrum and the patient has hearing loss. Question: Are all of these procedures appropriately reported with CPT code 69210, Removal impacted cerumen requiring instrumentation, unilateral? 

Answer: No. Only the third scenario listed above would be reported with CPT code 69210. A major element in determining whether code 69210 should be reported is based
upon an understanding of the definition of impacted cerumen. The AAO-HNS defines cerumen as impacted if any one or more of the following conditions are present:

 Cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition;

• Extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, hearing loss, etc;

• Cerumen is associated with foul odor, infection, or dermatitis; or

• Obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician skills.

Another key factor in determining whether code 69210 should be reported is what instruments are utilized to remove the impacted earwax. In this context, instrumentation is defined as the use of an otoscope and other instruments such as wax curettes and wire loops, or an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angle forceps). Accompanying documentation should indicate the time, effort, and equipment required to provide the service. Additionally, the descriptor of code 69210 has been clarified to reflect that code 69210 is a unilateral code. For bilateral 
impacted cerumen removal, report code 69210 with modifier 50, Bilateral Procedure, appended.


Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting of code 69210. Rather, that work would appropriately be reported with an evaluation and management (E/M) code regardless of how it is removed (eg, lavage, irrigation, etc). therefore, based on this information, scenarios 1 and 2 would not be reported with code 69210. These scenarios would be reported with the appropriate E/M code. Scenario 3, however, would be reported with code 69210 because both criteria were met: the patient had cerumen impaction and the removal required physician work using an otoscope or other magnification and instrumentation, rather than simple lavage.  



When removal of impacted cerumen is not covered

Simple cerumen removal when performed by the physician or office personnel (e.g., nurses, office technicians) should not be separately reported and is not separately payable when the definition of impacted cerumen is not met.

An E&M service and the removal of impacted cerumen are not separately payable when the sole reason for the patient encounter is for the removal of impacted cerumen. 

The patient is asymptomatic (e.g., denies pain, hearing loss, vertigo, etc.). 

Visualization aids, such as, but not necessarily limited to, binocular microscopy, are considered to be included in the reimbursement for 69210 and G0268 and should not be billed separately.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: 69209, 69210, G0268

Note: effective 1/1/2014 CPT 69210 describes a unilateral procedure. To report a bilateral procedure, append modifier -50 with “2” in the units field.  

Q: Does UnitedHealthcare Community Plan accept modifier 50 on all codes where the CPT book indicates coding guidelines to report modifier 50 when performing the procedure bilaterally?

A: No. UnitedHealthcare Community Plan follows the CMS NPFS Bilateral Procedures payment indicators "1" or "3" to determine which codes are eligible for bilateral services. For example, CPT code 69210 Removal impacted cerumen requiring instrumentation, unilateral (even though the CPT book indicates to bill with modifier 50 if done bilaterally) would not be reimbursable if billed with a modifier 50 since the CMS NPFS payment indicator is “2”, not “1” or “3” 

1/1/2014 New information added to Billing/Coding section: Effective 1/1/2014 CPT 69210 describes a unilateral procedure. To report a bilateral procedure, append modifier -50 with “2” in the units field. (adn)




Can a family practitioner bill for CPT 95811

Ans: No it’s for respiratory procedure that is pulmonology, it’s only done by specialist or technician


Solution: If it was billed, we need take write/off or proceed as per client’s instruction.



Can we use 59 modifier on CPT 81002 with 99213

Ans: We can not use.

 Solution: But we can use Mod 25 for CPT 99213.



Can we get paid for test that are not CLIA waived

Ans: We can not get payment.


Summary

Effective January 1, 2014, CPT code 69210 (most commonly known as cerumen removal) underwent a significant description change.

The new description of CPT code 69210 is as follows:

Removal, impacted cerumen requiring instrumentation, unilateral

What does this mean? Here are a few criteria that need to be met when reporting CPT code 69210:

• The procedure must be performed by a physician or other qualified health care professional (i.e.– NP, PA, CNS)

• The cerumen impaction must require the use of instrumentation such as a curette, ear spoon or forceps CPT code 69210 may no longer be reported for:

• Removal of cerumen that is not impacted

• Removal of cerumen using irrigation or lavage

• Removal of cerumen using manual techniques other than instrumentation (i.e. - cotton swabs)

• Removal of cerumen performed by a nurse, medical assistant or technicianRemoval of cerumen that does not meet the criteria required under the new definition is  considered to be included in the evaluation and management service rendered.

CPT also defines CPT code 69210 as a “unilateral” procedure that should be reported using a -50 modifier (bilateral procedure) if performed on both ears.


Seems pretty straightforward, doesn’t it? Well, “hear” is the issue. The Centers for Medicare and Medicaid (CMS) published information in the 2014 OPPS Final Rule indicating that they will not accept CPT code 69210 with a -50 modifier. Medicare reimbursement for 69210 will only be made for one unit of service, regardless of whether one or two ears are involved. UCare will follow Medicare guidelines and will process claims for CPT code 69210 based on a unit of one. Claims submitted with a -50 modifier will deny. 


CPT CODE 99392 -  Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years)   -   average fee $100 - $110



99392 Early childhood (age 1–4 years) V20.2 Routine infant or child health check



1 comment:

Munaf said...

Can we use Gp modifier for CPT CODE 82962?

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