Q&A: Rejections for claims for removing impacted cerumen

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

Many times in the ED, codes for services provided are driven by the chargemaster structure in cooperation with either a charge sheet or a menu in the electronic health record. When this is the driver, it is very easy for the person entering the charges/services to enter a line item for the right ear and one for the left ear. This could be because they are not versed in coding rules (modifiers -RT and -LT equal -50) for the surgical procedures. They may not be thinking of this as a “surgical procedure” as clinically it was “just an irrigation.” Or, there may not be an option for a bilateral procedure on the menu. It may be that the system is responsible for changing two unilateral procedures to report as a bilateral procedure, and this translation is broken. Follow the process through and see where the disconnect is.

CMS also changed the medically unlikely edit (MUE) number for CPT code 69209 as of April 1, 2017. Prior to April 1, the MUE was 2; however, this was changed to 1 as of April 1. You may want to check your claims prior to April 1 dates of service to insure that the payment you received was correct based on the bilateral payment methodology under the OPPS.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question. This Q&A originally appeared in Revenue Cycle Advisor.