Q.What modifier can I use for CPT Code 69210 (removal impacted cerumen, [separate procedure], one or both ears) for Medicare? I used left and right, but the claim was denied as an incorrect modifier.

A.Because the definition of the code includes either or both ear(s), you should not attach a modifier to indicate the right (-R), left (-L), or bilateral (50) ear(s).

Q.My physicians like to give Zofran injectable intramuscular; we generally don’t give it intravenously. The HCPCS code I found for it is J2405 (injection, ondansetron hydrochloride, per 1 mg), which is I believe is what one would use if you give it intravenously. Is there another specific code for just IM for Zofran?

A.The supply code is the same for the Zofran (J2405, injection, ondansetron hydrochloride, per 1 mg), whether it is administered IV or IM. You would also add the code for the IM injection procedure: 96372 (therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). If you are coding for an IM injection procedure on the same date you are coding for an E/M, then Medicare rules require modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of a procedure or other service) on the E/M code.

Q.During UCA’s fall course in Dallas, Dr. Stern gave me an add-on code that could be used with any code filed that is S9088 (services provided in an urgent care center). However, one of my colleagues took the experienced coders course and was told that the reimbursement rate on the S-code is very little in comparison to CPT code 99051 (services rendered during extended hours). Which do you recommend using as an additional code for additional reimbursements?

A.Either code may be added to appropriate visits. It is even compliant to code both on the same claim if both apply. Many visits do not qualify for 99051 (ie, evening, weekends, or holidays), so your only choice for an add-on code is the S9088 on these visits. Yes, it is true that payors are more likely to reimburse for 99051 and often pay more. Some payors do not reimburse for either code. However, every payor is different, so you should consult with each payor to understand its policies.

Q.What would you suggest for the billed amount for CPT code 99051 (services rendered during extended hours)?

A.I would suggest that you evaluate your current fee schedules with payors and make sure that your charge is at least equal to or above the highest fee that a contracted payor will reimburse for this code.
Note: CPT codes, descriptions, and other data only are copyright 2011, American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.
David E. Stern is a partner in Physicians Immediate Care, operating 18 clinics in Illinois, Oklahoma, and Nebraska. Dr. Stern was a Director on the founding Board of UCA and has received the Lifetime Membership Award of UCA. He serves as CEO of Practice Velocity (www.practicevelocity.com), providing software solutions to over 750 urgent care centers in 48 states. He welcomes your questions about urgent care in general and about coding issues in particular.
DAVID STERN, MD (Practice Velocity)

Modifier for 69210, HCPCS for IM Zofran, S9088 vs 99051, and Billed Amount for 99051

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine
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