-59 Modifier
By: Jimmie Hebert, CMC, CMIS, CMOM

CPT has some very specific rules for the use of modifier -59.  This modifier is considered the modifier of last resort.  You will typically use this modifier when no other modifier seems to fit.

Medicare and CPT have the same definition for this modifier.  It is used for services that are not normally reported together but are appropriate under the circumstances.

These circumstances may represent:

• different sessions or patient encounters
• different procedure or surgery
• different site or organ system
• separate incision or excision
• separate lesion
• separate injury
• services not normally encountered or performed on the same date by the same physician

Billing Medicare for Removal of Impacted Cerumen
By Sandie Becker, CMC
Santa Clara County Medical Association Reimbursement Specialist

If you are having trouble getting paid for CPT 69210 by Medicare, there is a reason for it. This code may be under your Local Medical Review. Some Medicare carriers are finding that many physicians are billing this procedure inappropriately. For example: 69210 were billed but documentation does not indicate that cerumen was removed. As a result, Medicare is flagging these claims and you may receive a 'development letter'. These letters are sent to providers when Medicare is requesting additional information regarding a claim, or is requesting clarification of claims data. If you receive one of these letters, you must send in copies of your documentation within 45 days supporting the need for the cerumen removal. Here is the caveat; even after sending in your documentation you may still get a denial. Why? One word: documentation.
Here are some reasons for denials:

• The most common reason for denial is due to lack of medically necessary justification noted on the submitted documentation. Most documentation Medicare is receiving indicates that the patient's are asymptomatic and have no complaints regarding the impacted cerumen. (In most cases, the physician is simply stating "ear wax" on physical exam.) This is not acceptable. If you are billing for cerumen impaction removal, your patient needs to be symptomatic (partial hearing loss, itching, tinnitus, otorrhea, sensation of fullness in the ear or pain) which is directly related to the presence of impacted cerumen and this needs to be clearly stated in your documentation. If you remove cerumen that is asymptomatic, non-impacted, and non-obstructive, this does not require a physician's skill and should not be separately billed. (See below).
• The second reason for denial is due to lack of justification indicated on the documentation for the frequency of services. If you are having to do this procedure as frequently as two or three times in a three month time period, your documentation needs to be specific as to why this is necessary with this particular patient. In other words, why does this patient seem to be having an excess of earwax that they need to have it removed on a frequent basis?
• The third highest reason for denial is due to documentation that usually does not support or indicate that the service had been rendered. The physician documents the cerumen of ears but does not state the removal procedure on the submitted documentation. You should not only indicate the procedure used to remove cerumen, your documentation should also reflect other methods were tried to remove the wax prior to the 69210.

When the provider uses a simple instrument like a curette to remove simple external earwax, the service is not payable separately. This method of earwax removal is included in the Evaluation & Management (E/M) services performed on the same day.

If the patient visits the physician for the sole purpose of symptomatic impacted cerumen, an E/M visit should not be billed; The Evaluation & Management services are in included with the 69210 However, if your patient is being seen for a significant, separately, identifiable service (such as diabetes, or a specific complaint not related to the ear) but then it is discovered by the physician or mentioned by the patient that there is cerumen impaction and the 69210 is performed and documented as discussed above, then the Evaluation & Management code may be billed along with the 69210. Don't forget the modifier 25 on the E &M code.

Scenario for billing 69210:

A patient complains of hearing problems, a problem that seems to occur every 2-3 months. The physician examined the patient, and determined that the patient's ears are impacted with cerumen, just as they had been 2.5 months ago. Since this was the patient's only complaint and didn't report any other medical problems, the physical exam was limited to the problem area at hand. The physician removed the impacted cerumen and the patient was told to contact the office if the problem recurs.

Your claim should look like this:

CPT:    69210                         ICD-9:              380.4 (impacted cerumen)
                                                                        V41.2 (problems with hearing)

Reasoning:

• There is no evidence of a significant, separately identifiable E/M service.
• The patient has no noted changes in the medical history and exam.
• The reported problem is the same as previously reported and treated.
• The primary service was procedural, not evaluation and management.

Medical Necessity Denials - Local Coverage Determinations
Medical necessity denials due to local coverage determination (LCDs) continue to be one of the top claim denials by NHIC. LCD denials are identified by the claim adjustment reason code:

C050 - These are non-covered services because this is not deemed a "medical necessity" by the payer.

The Remittance Advice (RA) Code associated with these denials is:

N115 - This decision was based on a local medical review policy (LMRP) or Local Coverage Determination (LCD). An LMRP/LCD provides a guide to assist in determining whether a particular item or service is covered.

If you get a denial with these codes, you may look up the policy on the web at http://www.cms.hhs.gov/mcd/search.asp. You may search for the LCD on CPT codes and ICD.9 codes among other things. The LCDs specify under what clinical circumstances a service is considered to be reasonable and necessary and will provide, along with other clinical guidelines, the ICD-9 codes that support medical necessity. If you do not have web access, you can request a copy of the LCD by contacting your Carrier.

PMI launches new Job Bank to help physicians and job seekers connect

Would Somebody Please Give Me a Break - Part II
A special commentary by Ione Broussard, CMC, CMIS, CMOM

In Part 1 of this article, I discussed how stress manifests itself in our lives. It's inevitable in today's world that we will encounter stress on a regular basis. I left off last time with the promise to give you tips on how to keep stress at bay.

The good news is that there is a way out of most stressful situations. The key is to ask yourself what result or solution do you want to end up with and what is the best method to achieve it?

Stress Management is the ability to maintain control when situations, people, and events make excessive demands. Tell that to your boss, your children, and the IRS while you're at it.

Here are some simple steps to help you achieve harmony when stress is eating you alive:

Step 1: Take A Deep Breath: slow down and breath deeply.

Step 2: Manage Time: don't over commit - plan ahead.

Step 3: Connect With Others: consider being a participant - help  yourself while helping others.

Step 4: Talk It Out: don't shout or yell it out - put out brushfires while they are still small.

Step 5: Take A Minute Vacation: change your "mental channel" - create a quiet scene and go there.

Step 6: Monitor Your Physical Comfort: too hot, too cold - try to make your environment just right.

Step 7: Get Physical: feeling nervous, angry or upset - release the pressure through exercise or physical activity.

Step 8: Laugh: maintain your sense of humor.

Step 9: Know Your Limitations: consider the fact we live in an imperfect world. - learn to accept what is, for now, until such time when you can change things.

Step 10: Consider Cooperation or Compromise: you don't have to continue pressing a point to prove that you are right.

Stress is unique and personal to each of us. Learning to control stress is the key to staying healthy and managing a positive workplace.

Finally, mental health is the ability to cope and adapt to change. Someone has said, ‘insanity is doing the same thing over and over expecting different result'. So…..you get to choose! Choose wisely and take care of yourselves, we have enough crazies out there already and some days I think I am one of them.