Coding Category

Myringotomy Includes Cerumen Removal

When reporting myringotomy (incision of eardrum) procedures (e.g., 69420 Myringotomy including aspiration and/or eustachian tube inflation and 69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia, do not separately report cerumen (earwax) removal for the same ear, using either 69210 Removal impacted cerumen requiring instrumentation, unilateral or an E/M code.

CMS’ National Correct Coding Initiative (NCCI) bundles cerumen removal into myringotomy codes 69420 and 69421. In addition, Chapter I of the “General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services,” states, “Since a myringotomy requires access to the tympanic membrane through the external auditory canal, removal of impacted cerumen from the external auditory canal is not separately reportable.”

If a physician or qualified practitioner must use instrumentation to remove, from a different ear, cerumen that has become impacted, you may separately report 69210 and append an appropriate modifier to indicate that the myringotomy and cerumen removal occurred at different locations. To ensure proper reporting of 69210, documentation in the medical record should ideally include:

  • Location of impacted cerumen (left ear, right ear, or bilateral)
  • Instrumentation and/or magnification used, including otoscope and/or operating microscope
  • Method of removal (forceps, suction, curettes, etc.)
  • Time and effort
  • Patient instruction given, and outcome

Prior to Jan. 1, 2015 the most appropriate modifier to append when reporting 69210 for removal of cerumen from a different ear is modifier 59 Distinct procedural service. From Jan. 1, 2015 on, the more appropriate modifier choice for Medicare payers is modifier XS Separate Structure, which CMS created to describe services that are separate because they are performed on different anatomic organs, structures, or sites.

September 19th, 2014

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CMS Clarifies Hospice Coding and Billing Instructions

The Centers for Medicare & Medicaid Services (CMS) Change Request (CR) 8877 updated Medicare hospice manual instructions for acceptable principal diagnosis codes and timely filing of Notice of Election (NOE), as well as coding guidance for skilled versus non-skilled nursing facilities. Changes are effective October 1.

Hospice Principal Diagnosis Coding Guidance

The coding instructions in CMS’ MLN Matters® 8877 for principal diagnosis state:

 … when the provider has established, or confirmed, a related definitive diagnosis, codes listed under the classification of Symptoms, Signs, and Ill-defined Conditions are not to be used as principal diagnoses. Hospice providers may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-9-CM/ICD-10-CM Coding Guidelines and that require further compliance with various ICD-9-CM/ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing or etiology/manifestation guidelines.

According to the ICD-9CM/ICD-10-CM Coding Guidelines both “debility” and “adult failure to thrive” are considered nonspecific, symptom diagnoses. Specifically, you should not use ICD-9-CM codes 799.3 (Debility, unspecified) and 780.79 (Other malaise and fatigue), ICD-10-CM code R53.81 (Other malaise); and ICD-9-CM code 783.7 and ICD-10-CM code R62.7 (adult failure to thrive) as principal hospice diagnoses on a hospice claim form. When any of these diagnoses are reported as a principal diagnosis, the claim will be returned to the provider for a more definitive hospice diagnosis based on ICD-9-CM/ICD-10-CM Coding Guidelines.

There also are several dementia diagnosis codes that you can’t use as the principal diagnosis because they are unspecified codes or have specific principal diagnosis code sequencing guidelines.

Timely Filing for Hospice NOE

There also are new time frames for submitting a NOE to Medicare administrative contractors (MACs). A NOE should be sent to, and accepted by, a MAC within five business days after hospice coverage is elected. If it’s not filed in a timely manner, the non-covered days are the provider’s liability, not the patient’s. There are exceptions to the five-day time frame; for example, natural disaster.

Q5003 vs. Q5004 Clarification

Excerpted from MLN Matters® 8877, the following is clarifying guidance for site of service HCPCS Level II codes Q5003 Hospice care provided in nursing long term care (LTC) facility or non-skilled nursing facility (NF) and Q5004 Hospice care provided in Skilled Nursing Facility (SNF):

Q5004 should be used for hospice patients in a Skilled Nursing Facility (SNF), or in the SNF portion of a dually-certified nursing facility. There are four situations in which this would occur:

  1. If the beneficiary is receiving hospice care in a solely-certified SNF;
  2. If the beneficiary is receiving general inpatient care in the SNF;
  3. If the beneficiary is in a SNF receiving SNF care under the Medicare SNF benefit for a condition unrelated to the terminal illness and related conditions, and is receiving hospice routine home care; this is uncommon; or
  4. If the beneficiary is receiving inpatient respite care in a SNF.

If a beneficiary is in a nursing facility but doesn’t meet the criteria above for Q5004, the site should be coded as Q5003, for a long term care nursing facility.

This is not a change in policy regarding the correct usage of the two site-of service codes; it’s a clarification of policy.

Read More

Go to the CMS website for more extensive guidance on hospice coverage. See CR 8877 and MLN Matters® 8877 for the complete information.


September 12th, 2014

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CMS Introduces Four New Modifiers in Lieu of Modifier 59

The Centers for Medicare & Medicaid Services (CMS) is establishing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, which is used to designate a “distinct procedural service.”

Modifier 59 is the most widely used HCPCS modifier: It is defined for use in a wide variety of circumstances, and is often applied incorrectly to bypass National Correct Coding Initiative (NCCI) edits. This modifier is associated with considerable misuse and high levels of manual audit activity, leading to reviews, appeals, and even civil fraud and abuse cases. The introduction of subset modifiers is designed to reduce improper use of modifier 59 and help to improve claims processing for providers.

Transmittal 1422, Change Request 8863 provides that CMS is establishing the following new modifiers—referred to collectively as -X{EPSU} modifiers—to define specific subsets of the -59 modifier:

XE Separate Encounter: A service that is distinct because it occurred during a separate encounter

XS Separate Structure: A service that is distinct because it was performed on a separate organ/structure

XP Separate Practitioner: A service that is distinct because it was performed by a different practitioner

XU Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service

Although CMS will continue to recognize modifier 59 in many instances, per CR8863:

CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS … may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.

The implementation date for this change is Jan. 5, 2015. Initially, either modifier 59 or a more selective –X{EPSU} modifier will be accepted, although CMS has encouraged a rapid migration of providers to the more selective modifiers. For further instructions regarding this change check with your MAC.


Lynn Stuckert, LPN, CPC, CPMA, has 30 years of experience in large multi-specialty clinics and hospital systems as a nurse, chart auditor, educator, compliance manager and medical writer. Stuckert has held offices for AAPC’s City of Palms Chapter and the Health Management Association of Southwest Florida.

August 26th, 2014


Differentiate Per Vaccine/Per Component Coding for Immunizations

When immunizations are performed, you should submit codes for both the administration and vaccine supply; however, a code for the vaccine is not reported if the vaccine is given to the provider for free, the patient brings the supply, or the supply is provided as part of a clinical trial.

There are three sets of administration codes: 90460/90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional…, 90471/90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections)…, and 90473/90474 Immunization administration by intranasal or oral route….

When reporting 90460-90461, you must verify that counseling was performed and that the patient is 18 years old or younger.

Another common mistake is reporting incorrect units. Codes 90460 and 90461 (unlike 90471-90474) are not reported by the vaccine administered, but per component. When combination vaccines are given, code for each component.

Example: A 1-year-old female is administered MMR and DTaP. During the visit, the provider discusses the benefits of each vaccine and potential side effects, and how to care for the side effects. The codes reported include:

MMR: 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered, 90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure) x 2, 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

DTaP: 90460, 90461 x 2, 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use.

August 21st, 2014

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OIG Continues to Focus on POS Errors, and So Should You

Once again, the OIG has included place of service (POS) errors as a focus of its annual Work Plan:

We will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Context—Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors.

POS errors are more than “clerical.” As the work plan explains, “Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ambulatory surgical center.” Therefore, if the assigned POS on a claim is incorrect, payment may be affected.

When assigning POS codes for Medicare claims, the POS must match the setting in which the patient received the service (for face-to-face services), or the setting in which the technical portion of the service was delivered (for non-face-to-face services, such as interpretation of diagnostic test results).

There are two exceptions to the rule:

  1. When a physician/practitioner/supplier furnishes services to a registered inpatient, the inpatient hospital POS code 21 shall be used, irrespective of where the face-to-face encounter occurs.
  2. Physicians/practitioners who perform services in a hospital outpatient department shall use, at a minimum, POS code 22 (Outpatient Hospital) unless the physician maintains separate office space in the hospitalor on the hospital campus and that physician office space is not considered a provider-based department of the hospital (see 42. C.F.R. 413.65). Physicians shall use POS code 11 (office) when services are performed in a separately maintained physician office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital.

The above guidelines were recently updated by Centers for Medicare & Medicaid Services (CMS) Transmittal 2679. For clarification, MLN Matters® Number: MM7631 Revised provides the following example.

“A beneficiary receives an MRI at an outpatient hospital near his/her home. The hospital submits a claim that would correspond to the TC portion of the MRI. The physician furnishes the PC portion of the beneficiary’s MRI from his/her office location—POS code 22 [outpatient hospital] will be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.”

Resource tip: You can find a complete list of POS codes on the CMS website.

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