Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27528

Removal of Impacted Cerumen

L27528

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-line Manual Pub. 100-3, Chapter 1, Section 70.3.

CMS On-line Manual Pub. 100-2, Chapter 15, Section 30. 

CMS On-line Manual Pub. 100-4, Chapter 12, Section 40.1 and Section 10.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Impacted cerumen removal is the extraction of hardened or accumulated cerumen from the external auditory canal by mechanical means, such as irrigation or debridement.

Generally, the simple/routine removal of cerumen (e.g., softening drops, use of cotton swabs and/or cerumen spoons) is considered a part of the office visit and therefore cannot be separately reimbursed on the same day as an Evaluation and Management (E&M) service.

Indications

Payment may be made for the removal of impacted cerumen when ALL of the following are met:

1. the service is the sole reason for the patient encounter,
   
   
2. the service is personally performed by a physician or non-physician practitioner, (i.e., nurse practitioner, physician assistant, clinical nurse specialist),
   
   
3. the service is provided to a patient who is symptomatic, and
   
   
4. the documentation illustrates significant time and effort spent in performing the service.

In the above situation the E&M service is included in the fee for the removal of impacted cerumen, therefore, an E&M service is not separately payable.

Payment consideration may be made for both the procedure and the E&M service if ALL of the following conditions exist:

1. The nature of the E&M visit is for something other than removal of impacted cerumen.
   
2. During an unrelated patient encounter (visit), a specific complaint or condition related to the ear(s) is either discovered by the physician or brought to the attention of the physician/non-physician practitioner by the patient.
   
3. Otoscopic examination of the tympanic membrane is not possible due to a cerumen obstruction in the canal.
   
4. The removal of impacted cerumen requires the expertise of a physician or non-physician practitioner and is personally performed by the physician or non-physician practitioner.
   
5. The procedure requires a significant amount of the physician's/non-physician practitioner's effort and time.
   
6. Documentation is present in the patient record to identify the above criteria have been met.

Limitations

Removal of impacted cerumen performed by someone other than the physician or non-physician provider is not billable.

Simple cerumen removal performed by the physician or office personnel (e.g., nurses, office technicians) is not medically necessary and therefore, not separately payable.

An E&M service and the removal of impacted cerumen are not separately payable when the sole reason for the patient encounter is for the removal of impacted cerumen.

The patient is asymptomatic (e.g., denies pain, hearing loss, vertigo, etc.).

Visualization aids, such as, but not necessarily limited to, binocular microscopy, are considered to be included in the reimbursement for 69210 and G0268 and should not be billed separately.

Most patients do not require medically necessary disimpaction of cerumen by a physician. Patients who require this service more often than 3-4 times per year would be unusual.

NOTE: If this service is performed in the skilled nursing facility and/or nursing facility, please see LCD #L27485, LCD #L27496, and NCD 70.3, for additional guidance.

Surgical Services, Outpatient Hospital Services, Doctor Office Visits

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. When this service is reported in addition to an E&M service, the medical record must clearly reflect that the procedure was separate from the reason of the E&M encounter.
   
   
5. The documentation in the medical record must clearly reflect the service required a significant amount of physician effort and time and was personally performed by the physician or non-physician practitioner.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Patients who require this service more than 3-4 times per year are unusual.  If this service is required more than 4 times per year, the documentation should clearly indicate the medical necessity of this service.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27528

07/31/2008

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