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Medical Coding News Archives

Impacted Cerumen: Medicare to Deny Claims, Contrary to AMA Coding Instructions

March 21, 2014:

Nannette Orme, Clinical/Technical Editor

Providers following the CPT® manual’s 2014 guidelines for reporting the removal of impacted cerumen will have a rude awakening when Medicare and many private payers deny their claims.

The American Medical Association’s revised code description of 69210 for 2014 is “Removal impacted cerumen requiring instrumentation, unilateral.” A new guideline under the code in the CPT manual reads: “For bilateral procedure, report 69210 with modifier 50.” The old description was “Removal impacted cerumen (separate procedure one or both ears).”

Although the AMA considers code 69210 to be unilateral, Medicare Part B is rejecting the code when billed with modifier 50, RT, or LT or when more than one unit of service is reported. The relative value units for this code are the same as they were last year, and the Medicare physician fee schedule still considers this code bilateral. The medically unlikely edits (MUE) still allow only one such service per day.

The American Academy of Otolaryngology—Head and Neck Surgery is advising its members to follow the Centers for Medicare and Medicaid Services’ coding instructions, noting that many private payers are following Medicare’s lead. The AAO-HNS reports that Medicare audit contractors are denying even one unit if code 69210 is reported incorrectly.

According to the AAO-HNS, CMS argues that the causes of cerumen impaction usually affect both ears. The academy will gather data this year on how often impacted cerumen requires procedures on both ears and report its findings and recommendations to CMS in time for the agency to adjust its payment policy for 2015, if warranted.

Impacted cerumen affects an estimated 2 percent to 6 percent of the general U.S. population but one in three older adults in the United States. The condition accounts for 12 million visits to health care providers per year.

Both the AMA and CMS consider simple removal of wax and use of irrigation and lavage only as part of the evaluation and management service. Both also require use of instrumentation, such as an otoscope, wax curettes, and cup forceps, when listing code 69210.

Claims with code 69210 that have been denied can be resubmitted using only the correct modifiers and units of service.


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