procedure code and description
69209- Removal impacted cerumen using irrigation/lavage, unilateral – average fee payment – $10 -$20
69210 Removal impacted cerumen requiring instrumentation, unilateral
G0268: Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing
Here are a few criteria that need to be met when reporting procedure 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
procedure 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.
procedure also defines procedure 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 procedure 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 procedure code 69210 based on a unit of one. Claims submitted with a -50 modifier will deny.
Incident Rule
69210
G0268
Incidental 99201-99489
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.II. Payment consideration may be made for both the procedure and the E&M service if all of the following conditions are met:
1. The diagnosis of the E&M visit is other than the 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 the physician or brought to the attention of the physician/non-physician practitioner by the patient.
3. The definition of impacted cerumen is met according to Section I of this policy.
4. Documentation is present in the patient record to identify the above criteria (II.1-3) have been met.
5. A -25 modifier must be submitted with the E&M code for proper adjudication to indicate a significant, separately identifiable evaluation and management service was performed.
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.
Policy Guidelines
Documentation Requirements:
When this service is reported in addition to an E&M service, the medical record must clearly reflect the procedure was separate from the reason for the E&M encounter.
The documentation in the medical record must clearly reflect that the service required significant effort and time of the physician or non physician practitioner.
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
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 procedure 69210 describes a unilateral procedure. To report a bilateral procedure, append modifier -50 with “2” in the units field.
DESCRIPTION
Cerumen impaction is a condition in which earwax has become tightly packed in the external ear canal to the point that the canal is blocked. Extraction requiring methods beyond simple irrigation or removal by Q-tip or cotton-tipped applicator may require a physician’s skill. Cerumen, or ear wax, is the product of desquamated skin mixed with secretions from the adnexal glands of the external ear canal. It provides lubrication and acts as a vehicle for the removal of contaminants away from the tympanic membrane and prevents dessication of the epidermis.
Though usually asymptomatic, cerumen can accumulate and become impacted causing such symptoms as conductive hearing loss, pain, itching, cough, dizziness, vertigo, and tinnitus. Hearing impairment can further contribute to stress, social isolation, and depression. Impacted cerumen can also impede the evaluation and management of other otologic conditions.
Depending on the case, different methods are used to remove impacted cerumen. Simple irrigation with a bulb syringe with or without chemical softeners is often effective and generally does not require a physician’s skill.
Forced irrigation with a metal hand-held syringe or an electric oral jet irrigator may be necessary in some cases.
A few may need manual disimpaction under direct vision using suction, probes, forceps, hooks or other instruments. Cases requiring methods beyond simple irrigation or removal by Q-tip or cotton-tipped applicator may require a physician’s skill.
POLICY
Impacted cerumen removal (69209, 69210, G0268) does not require prior authorization for HMO, PPO, Individual Marketplace, & Elite.
Impacted cerumen removal (69209, 69210) does not require prior authorization for Advantage.
Procedure G0268 is non-covered for Advantage.
HMO, PPO, Individual Marketplace, Elite, Advantage Paramount covers impacted cerumen removal when performed by a physician or other qualified health care professional (i.e., NP, PA, CNS) if:
* Medically necessary removal of symptomatic impacted cerumen requires the use of instrumentation such as a curette, ear spoon or forceps (69210) or requires the use of irrigation and/or lavage but without instrumentation (69209)
* Medically necessary removal of impacted cerumen impedes their ability to properly evaluate or manage other signs, symptoms or conditions (e.g., examination of the tympanic membrane in cases of otitis media)
* Medically necessary removal of impacted cerumen impedes their ability to perform medically necessary audiometry Payment may be made for both removal of impacted cerumen and an evaluation and management (E/M) service (with appropriate modifier appended), only if the E/M service represents a medically necessary, significant and separately identifiable service that is supported by medical record documentation. The documentation should clearly support that a significant amount of the physician’s time and effort were required.
This includes a procedure note supporting the time, interventions, and how the patient tolerated the procedure.
The time spent removing the cerumen cannot be included in the time spent performing the E/M service. If the cerumen must be removed in order to examine the ears, the removal is considered a component of the examination portion of the E/M service.
Note: procedure codes 69209 and 69210 describe a unilateral procedure. To report a bilateral procedure, append modifier – 50 with “1” in the unit field.
Procedure code G0268 should only be billed when a physician’s expertise is needed to remove impacted cerumen on the same day as audiologic function testing, performed by his 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, Paramount can pay audiologists only for medically necessary diagnostic testing, which is considered to include any incidental cerumen removal by the audiologist. Paramount cannot reimburse audiologists for procedure code 69209, 69210 or G0268 under any circumstances.
Procedure G0268 is non-covered for Advantage.
Paramount does not support separate reimbursement for:
* Removal of cerumen that is not impacted
* Removal of cerumen using manual techniques other than instrumentation (i.e., cotton swabs)
* Removal of cerumen performed by a nurse, medical assistant or technician Visualization aids, such as, but not necessarily limited to binocular microscopy are considered included in the reimbursement for 69209, 69210 and G0268 and should not be billed separately.
