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AAO-HNS Statement on Reimbursement of CPT 69210 and Evaluation and Management Services

AAO-HNS Statement on Reimbursement of CPT 69210 and Evaluation and Management Services

The American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS), with approximately 12,000 members nationwide, is the national medical association of physicians dedicated to the care of patients with disorders of the ears, nose, throat, and related structures of the head and neck. The medical ailments treated by this specialty are among the most common that afflict all Americans, old and young, including hearing loss, balance disorders, chronic ear infections, rhinological disorders, snoring and sleep disorders, swallowing disorders, facial and other cranial nerve disorders, and head and neck cancer.

The AAO-HNS has heard from several members that private payers are denying all claims when CPT 69210 removal impacted cerumen requiring instrumentation, unilateral is billed in conjunction with any office based Evaluation and Management (E/M) CPT code. Some private payers have determined procedure 69210 is not reimbursable when submitted with any E/M service. Such a policy is inconsistent with correct coding and CPT® guidance, and therefore should be reconsidered. The health policy staff tracks issues like this one involving private payer policies regarding CPT 69210 and E/M services. While the AAO-HNS cannot represent physician members individually on each issue with private payers, we do work to provide resources to assist members on nationwide reimbursement matters. As a result, the AAO-HNS, working with the Physician Payment Policy (3P) workgroup, has developed this statement and template appeal letter to assist members with their appeal efforts.

Per coding guidance from the American Medical Association’s CPT® book and October 2013 CPT® Assistant article1, and consistent with AAO-HNS CPT for ENT article on our website2, the AAO-HNS supports the reporting of 69210 with an E/M on the same date of service in certain instances, and believes both should be separately reimbursed when the criteria for reporting the separate services are met. The mandatory criteria to report these services together include:

  1. The initial reason for the patient’s visit was separate from the cerumen removal;
  2. Otoscopic examination of the tympanic membrane is not possible due to the impaction;
  3. Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner and is personally performed by him or her; and
  4. The procedure requires a significant amount of time and effort, and all of the above criteria are clearly documented in the patient’s medical record.

August 2014

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