If you have the inside scoop on Medicare's carve-out policy for 69210/modifier 25, you can focus on winnable denials and get the best ethical pay-up for encounters involving an office visit, impacted wax removal, and/or microscopy
Insurers are bundling 69210 (Removal impacted cerumen [separate procedure], one or both ears) and 92504 (Binocular microscopy [separate diagnostic procedure]) with a same-day E/M service (such as 99213-25, Office or other outpatient visit for the evaluation and management of an established patient -; Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Sometimes, you should appeal for payment, but in other cases the payer is right. Test whether you-re zooming in on worthwhile appeals with the following sample claim.
Case study: A payer denies microscopy when billed with impacted cerumen removal. The claim contains:
- 99213-25, 389.10
- 69210, 380.4
- 92504, 389.10. Don-t: Report 69210 and 92504 Together Solution: The claim should contain only one procedure code. -You can code either the impacted cerumen removal or the microscopy, not both,- says Julie Keene, CPC, an otolaryngology coding and reimbursement specialist at University ENT Specialists in Cincinnati. These codes are listed as -separate procedures- in the CPT book.
Procedures with descriptors containing this term -are commonly carried out as an integral component of a total service or procedure,- state CPT's separate-procedure notes. These codes -should not be reported in addition to the code for the total procedure or service of which it is considered an integral component,- according to surgery guidelines.
Impact: When a physician performs a separate procedure and another procedure in the same area, CPT includes the separate procedure in the other procedure, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders based in Salt Lake City. So, if the otolaryngologist does anything in the ear and microscopy, CPT includes 92504 in the other ear procedure and the microscopy is not billable. Similarly, if the ENT performs any ear procedure and also removes impacted cerumen, 69210 is included in the other ear procedure and is not billable. Do: Realize Payers Treat 69210 as Incidental Because you should bill only 69210 or 92504 in the above claim, you should first look at the problems caused by reporting an office visit in addition to 69210.
On claims for an office visit and 69210, Medicare will only pay for the office visit, says Brenda Kohli, with ENT Head & Neck Specialists PA in Wyomissing, Pa. -I have tried modifiers with no luck,- she adds. The carrier will pay for 69210 when Kohli bills the procedure alone. [...]