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)






Current procedural terminology (CPT) 69210

The 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.

Description of Procedure or Service 

Impacted cerumen removal is the extraction of hardened or accumulated cerumen (ear wax) from the external auditory canal by mechanical means, such as irrigation or debridement.

Generally, the simple/routine removal of cerumen (e.g., softening drops, use of cotton swabs and/ or cerumen spoons) is considered a part of the office visit and therefore cannot be separately reimbursed on the same day as an Evaluation and Management (E&M) service.

When removal of impacted cerumen is covered

I. Payment may be made for the removal of impacted cerumen when the service is the sole reason for the patient encounter, and when the definition of impacted cerumen is met. To be considered clinically impacted cerumen, the physical findings must be consistent with one or more of the following:

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

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

3. Inflammatory considerations. Associated with foul odor, infection, or dermatitis. 4. Quantitative considerations. Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentation requiring advanced practitioner skills. (physician or non physician practitioner, such as nurse practitioner, physician assistant, clinical nurse specialist). When cerumen removal is the sole reason for the encounter, the E&M service is included in the fee for the removal of impacted cerumen. Therefore, an E&M is not separately payable.


Cerumen Removal with Lavage

• Cerumen (from Latin cera “wax”) impaction
• CPT Assistant July 2005, page 14 C:UsersgedfordDesktopCPT 2016Cerumen Removal.pdf
• Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear conditions.
• Qualitative considerations: Extremely hard, dry, irritating cerumen causes symptoms such as pain, itching, hearing loss, etc.
• Inflammatory considerations: Associated with foul odor, infections or dermatitis
• Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations require physician skills.


• 69209 – Removal impacted cerumen using irrigation/lavage, unilateral
– (Do not report 69209 in conjunction with 69210 when performed on the same ear)
– (For bilateral procedure, report 69209 with modifier 50)
– (For removal of impacted cerumen requiring instrumentation, use 69210)
• 69210 – Removal impacted cerumen requiring instrumentation, unilateral
• (Do not report 69210 in conjunction with 69209 when performed on the same ear
• (For bilateral procedure, report 69210 with modifier 50)
• (For removal of impacted cerumen achieved with irrigation and/or lavage but without instrumentation, use 69209)

Changes in Guidelines for Reporting CPT Code 69210

As a reminder, the definition of CPT code 69210 was changed as of Jan. 1, 2014, to read: 69210, removal of impacted cerumen requiring instrumentation, unilateral. (For bilateral procedures, report 69210 with modifier -50.) The American Medical Association (AMA) and CMS recently published reporting guidelines related to the above change. In support of the AMA and CMS guidelines, BCBSIL is providing the following information. When a substantial diagnostic or therapeutic procedure is performed, the Evaluation and Management (E/M) service is included in the global surgical period as defined by CMS.

Only a separately identifiable E/M service would be payable. Per guidance from the AMA (CPT Assistant October 2013) regarding reporting code 69210: …an E/M code may be reported if there is a separate and distinct service performed at the same session. In that instance, modifier 25, Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service, should be appended to the E/M code. Additionally, this position is reflected in the CMS National Correct Coding Initiative (NCCI) edits, which do not allow separate reimbursement for the E/M service when reported with code 69210 unless the visit is identified as a separately identifiable service. Therefore, if the surgical procedure 69210 is reported with an E/M code, the E/M visit is included in the payment of 69210. Unless the visit is reported as a separately identifiable service, above and beyond the usual preoperative visit, the E/M visit will not be reimbursed

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.

CLAIM AUDITING RULES AND CLINICAL RATIONALE

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you can use the Clear Claim ConnectionTM (C3) tool. C3 is a free, online reference tool that mirrors the logic behind BCBSIL’s code-auditing software, ClaimsXten®. Refer to the Education and Reference/Provider Tools section of our Provider website for additional information on C3 and ClaimsXten.

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






Cerumen Removal CPT code 69210 is a covered service.


Payment may be made for impacted cerumen (when ALL of the following are met): 1) the service is the sole reason for the patient encounter, 2) the service is personally performed by the physician or non-physician practitioner (i.e. nurse practitioner, physician assistant), 3) the service is provided to a patient who is symptomatic, and 4) the documentation illustrates significant time and effort spent in performing the service.


Effective January 1, 2014, CPT code 69210 is a unilateral procedure. Please refer to section 28.6.3 for billing of bilateral procedures. Payment consideration may be made for both the procedure and the E&M services if ALL of the following conditions exist: 1) The nature of the E&M visit is for something other than removal of impacted cerumen. 2) During an unrelated patient encounter (visit), a specific complaint or condition related to the ear(s) is either discovered by or brought to the attention of the physician/nonphysician practitioner by the patient. 3) Otoscopic examination of the tympanic membrane is not possible due to a cerumen obstruction in the canal. 4) The removal of impacted cerumen requires the expertise of a physician or non-physician practitioner. 5) The procedure requires a significant amount of the physician’/nonphysician practitioner’s effort and time. 6) Documentation is present in the patient record to identify the above criteria have been met.


Limitations:


• Removal of impacted cerumen performed by someone other than the physician or non-physician practitioner is not billable.


• Simple cerumen removal performed by the physician or office personnel (e.g., nurses, office technicians) is not medically necessary and therefore, not separately payable.


• An E&M service and the removal of impacted cerumen are not separately payable when the sole reason for 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 should not be billed separately.


Most patients do not require medically necessary disimpaction of cerumen by a physician. Patients who require this service more often than 3-4 times per year would be unusual. 


Non-covered Services Service Coverage and Conditions Acupuncture Acupuncture is not covered. 


After Office Hours


The following services are not covered: After office hours, services provided in a location other than the physician’s office, and office services provided on an emergency basis. Autopsies Autopsies are not covered.


Bariatric Procedures


Considered cosmetic unless specific medical criteria are met Biofeedback Biofeedback is not covered. Blood Tests Blood tests are not covered for marriage licenses. Casting and Supplies


Some surgical codes are considered an inclusive package of professional services and/or supplies and are not considered separately allowable or reimbursable as the fracture repair or surgical codes is inclusive of these services. An example of this would be a surgical code for a fracture repair which is inclusive of any casting and strapping services or supplies. 
Cerumen Removal


CPT Code 69210 is not covered if the ear wax is not impacted and the service does not meet the criteria outlined in section 28.2.2, Covered Services. Chiropractors Chiropractic services are not covered, except for QMB recipients and for services referred directly as a result of an EPSDT screening.


Chromosomal Studies 


Chromosomal studies (amniocentesis) on unborn children being considered for adoption are not covered. Medicaid can pay for these studies on prospective mothers in an effort to identify conditions that could result in the birth of an abnormal child.


Dressing and Compression Wrap Any dressing/compression wrap performed in conjunction with wound debridement is considered part of the debridement servicesand is not separately covered / billable.