As an audiologist, I am unclear about billing for cerumen removal. If we perform this service, do we need to bill Medicare even though they will not reimburse us for this procedure?
(Dr. Steven White) There currently is no code for cerumen "management." The CPT code for cerumen removal is a surgical code: 69210, removal of impacted cerumen. The key term in the title is "impacted." At the present time, if removal of impacted cerumen is necessary in order to complete audiological testing, then Medicare will pay for it but because it is not a diagnostic procedure audiologists are not eligible to provide the service. The physician would have to document that the cerumen was impacted and precluded complete audiological evaluation. Cerumen removal performed on the same day as the audiogram would be inclusive to the audiological evaluation. In most cases, however, we perform cerumen removal for hearing aid patients requiring hearing aid services, which we know are not covered benefits for Medicare beneficiaries.
(Dr. Kim Cavitt) Medicare has mandatory claims requirements. In this case, you would submit a claim to Medicare on the behalf of the Medicare beneficiary if the beneficiary requests that you do so. I am personally a huge advocate for the use of an Advance Beneficiary Notice (ABN). The ABN is a voluntary notification for situations such as this where the patient is given informed consent that the procedure can be performed, but it is not necessarily covered or paid by Medicare. The cost of the procedure would then be delegated to the patient.
By signing the ABN, they understand that they could have the cerumen removed by another medical specialty that Medicare recognizes for reimbursement, but they have chosen to pay for it privately. Then, on the ABN form, the patient determines whether or not they want that claim submitted to Medicare for denial. In some cases, patients have a secondary insurance that may pick up that cost on their behalf, but the primary insurance, or Medicare, must be billed with a denial decision first. So, yes, you do need to submit a claim to Medicare if requested by the patient to do so.
Editor's Note: This Ask the Expert was taken from the live e-seminar The Potential Risks Versus the Need for a Comprehensive Medicare Benefit recorded 6/16/2011. To access the complete course, please go here. www.audiologyonline.com/ceus/recordedcoursedetails.asp?class_id=18818
Kim Cavitt, Au.D. spent nine years as a clinical audiologist and preceptor at both The Ohio State University and Northwestern University and spent two years as the Director of Professional Relations at HearPO. For the past ten years, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. Audiology Resources, Inc. provides comprehensive operational and reimbursement consulting services to hearing healthcare clinics, providers, organizations, buying groups, and manufacturers who want to be better equipped to compete in the managed care and healthcare arenas. She also currently serves on committees through ADA, AAA and ASHA and is an Adjunct Lecturer at Northwestern University.
Steven C. White, Ph.D., CCC-A, is the Director of the Health Care Economics and Advocacy at the ASHA, and has spent thirty years in government relations at ASHA. White, an ASHA Fellow, is ex officio of the Health Care Economics Committee and staff liaison to the Current Procedural Terminology Editorial Panel and the Relative Value Update Committee. He is co-author of Health Plan Coding and Claims Guide, Negotiating Health Care Contracts and Calculating Fees, Appealing Health Plan Denials, Medicare Handbook for Audiologists and Medicare Handbook for Speech-Language Pathologists. He holds a M.S. in speech-language pathology and audiology from Ithaca College and a Ph.D. in audiology from Wayne State University.