Health insurer Cigna recently announced that, starting Nov. 14, it will deny office visit evaluation and management (E/M) services as not separately payable when billed with the removal of impacted cerumen if the removal is the sole reason for the visit. This update affects E/M CPT codes 99202-99205 and 99211-99215 when billed with cerumen removal codes 69209 or 69210.
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When reporting an E/M visit and cerumen removal on the same date of service, the following criteria should be met:
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- The main reason for the patient’s visit was separate from the cerumen removal,
- Otoscopic examination of the tympanic membrane was not possible due to impaction,
- Removal of the impacted cerumen required the expertise of a physician or non-physician provider,
- The procedure required a significant amount of time and effort, and all the above criteria were clearly documented in the patient’s medical record.
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When all of those conditions are met, an appropriate office visit E/M code may be reported with 69209 or 69210. Modifier 25 (significant and separately identifiable E/M service by the same physician on the same day of the procedure or other service) should be appended to the E/M visit code. Clinic notes must demonstrate that the E/M and the cerumen removal are separate services.
Here’s an example note, with codes:
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Patient presents with right ear pain and sinus draining. Upon examination, the physician notes an impacted cerumen that was severely impacting the external auditory canal of the right ear. This would have to be removed with instrumentation, not simple lavage. The physician asked the MA to prep the patient for the minor procedure removal, with appropriate instrumentation. The otoscopic exam was challenging due to the deep impaction of the cerumen. The obstruction was removed, and the patient felt immediate relief and her hearing became improved. We will also give the patient a five-day trial of antibiotics, amoxicillin, for her sinus infection as well. Patient will call if sinus infection does not clear up in a week.
CPT and ICD-10 codes: 99213-25, J01.80 and 69210 H61.21
— Brennan Cantrell, commercial health insurance strategist, American Academy of Family Physicians
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