Coding for Cerumen Removal
CMS responded to the Academys plea to correct the National Correct Coding Initiative (NCCI) bundling of 69210 (removal impacted cerumen (separate procedure one or both ears) and audiometric testing by developing a HCPCS Level II code, G0268 (Removal of impacted cerumen (one or both ears) by physicians on same date of service as audiologic function testing). At this writing, these NCCI edits remain in place and may be adopted by some commercial carriers. Although G-codes are typically only used by CMS/Medicare, carefully check the payment policies of carriers in your locale. The relative value units (RVUs) for physician work, practice expense and malpractice remained the same as for CPT code 69210.
Medicare will not cover cerumen removal performed by an audiologist. For Medicare patients, the physician should only bill G0268 when removing cerumen on the same day as audiology testing. Independent audiologists cannot bill G0268.
Typically, Medicare will not cover simple, non-impacted earwax removal. This work is included in the E/M service.
CMS requires that physicians meet the following criteria for reimbursement of the removal of impacted cerumen:
- The procedure is the sole reason for the patient encounter;
- A physician or non-physician (nurse practitioner, physician assistants, or clinical nurse specialist) carries out the treatment.
- The patient in question is symptomatic; and
- The supporting documentation shows significant time and effort spent performing the service.
Furthermore, for CMS reimbursement of an E/M visit and cerumen removal, the following criteria must be met:
- The initial reason for the patients visit was separate from the cerumen removal.
- Otoscopic examination of the tympanic membrane is not possible due to the impaction;
- Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner and is personally performed by him or her; and
- The procedure requires a significant amount of time and effort, and all of the above criteria are clearly documented in the patients medical record.
When all of the above conditions are met for both Medicare and commercial carriers, report an applicable E&M, G0268 (for Medicare or 69210 for commercial carriers), and the appropriate audiometric function test codes (CPT Codes 92553 through 92598, except for non- covered codes 92559 and 92560) appending a modifier 25 (significant and separately identifiable evaluation and management service by the same physician on the same day of the procedure or other Service) to the E&M visit. It is imperative that your clinical notes demonstrate that the E&M and the cerumen removal are separate services. Finally, it is important to include the ICD-9 code 380.4, impacted cerumen with a definition of ear wax, blocking the external ear canal on the claim.
Also, remember that G0268 is a bilateral procedure and should be reported with one unit of service, even if both ears were cleaned. The HCPCS/CPT code(s) may be subject to National Correct Coding Initiative (NCCI) bundling edits. Please refer to the NCCI for correct coding guidelines and specific applicable code pairs prior to claim submissions.
- A patient scheduled for audiometric function testing is found to have impacted cerumen in both ears. The physician personally cleans the ear canals and documents significant work for the service. The practice groups audiologist performs the audiometric testing. How should this be reported?
The doctor (with his or her NPI) should report, G0268, ICD-9-CM code 380.4. The audiologist (with his or her NPI) should report the appropriate audiometric testing code(s). Both parties can assign payment to the practice(s).
- A patient presents with vertigo but physician finds that the patient has impacted cerumen in both ears. The physician removes the impacted cerumen and examines the patient for the vertigo. How should this be reported?
The physician should report 69210, ICD-9-CM code 380.4, the appropriate E&M code appended with modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service and ICD-9-CM code 780.4 -dizziness and giddiness- lightheadedness; Vertigo NOS. Ensure that your supporting documentation shows that the initial reason for the patients visit was separate from the cerumen removal.
Reviewed August 2006
Reviewed April 2009
Revised March 2010