Removal of Impacted Cerumen Requiring Instrumentation

Reimbursement Policy:
Removal of Impacted Cerumen Requiring Instrumentation

Effective Date:
November 16, 2015

Purpose:
Provide guidelines for the reimbursement of one (1) unit of CPT® Code 69210 per date of service for the Medicare Advantage product, even if billed bilaterally, which is in alignment with the CMS Federal Register decision.

Scope:
Medicare Advantage Products Only

Policy:
Horizon BCBSNJ shall no longer reimburse beyond one (1) unit per date of service for CPT Code 69210 for the Medicare Advantage product.

This policy applies to both participating and non-participating professional providers

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
CPT code 69210 shall be reimbursed at one (1) unit per date of service, even if billed bilaterally, for the Medicare Advantage product.

In denied instances where the provider is participating, there shall be no member’s liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit

• Provider Participation Agreement

• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity

• Mandated or legislative required criteria will always supersede.

CPT is a registered trademark of the American Medical Association

Policy 089_v1.0_08012015