# Removal of impacted cerumen



## KristieStokesCPC

I have a patient who came in on 10/9/08, our MA did a removal of cerumen. She called the next day complaining about pain, she came back on the 20th. The wax was not completely removed so our physician did a repeat to remove the wax. Am I correct in saying that we can charge for the removal on both visits? And do I use a modifier 76 on the second removal even though the MA did the first removal, we bill everything with the physician as the supervisor.

Thank you


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## lisamilo

If the MA does the removal you cannot bill for it.  You can only bill when the doctor removes the wax with a currette, lighted spoon or uses a microscope.


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## Lisa Bledsoe

lisamilo is absolutely correct.  The procedure MUST be done by the doctor, PA or NP.


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## RebeccaWoodward*

Some time ago, Mary posted an excellent explanation for this scenerio.

https://www.aapc.com/MemberArea/forums/showthread.php?p=24392


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## Kris Cuddy

Very true, 69210 may only be billed when performed by the Physician or NPP. I tried to updload a couple of documents in relation to this but the file limit for aapc is too small. I've got a coding alert article and a clarification from BCBSM. If you'd like those, give your email address and I'll send them on.


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## okiesawyers

Lisa Curtis said:


> lisamilo is absolutely correct.  The procedure MUST be done by the doctor, PA or NP.



I agree. Absolutely correct!


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## KristieStokesCPC

Ok, so even though the nurse did it under the supervision of the physician with the utensils, we can't bill the 69210?


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## Lisa Bledsoe

Nope - the doctor/PA/NP must do it.


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## KristieStokesCPC

Thank you all so much, I understand although I'm completely confused at the same time  . Can you look at the physician note below and tell me if this is justified? Thanks again ....

Electronically signed by provider on  10/21/2008 04:45:38 PM                         
SUBJECTIVE:

CC: 
Ms. Patient is a 81-year-old female.  She presents with earache.  

HPI: 
Mrs Patient presents with complaint of both ears hurting for a couple of days.  She says that she has been dealing with watery eyes and runny nose that is so bad that it runs water when she bends over.  Now both of her ears hurt.  She denies fever or chills, cough or sore throat.  

ROS: 
CONSTITUTIONAL:  Negative for chills, fatigue, fever and night sweats.  
EYES:  Negative for blurred vision and eye pain.  
E/N/T:  See HPI 
CARDIOVASCULAR:  Positive for claudication, dizziness, pedal edema ( moderate ) and varicosities.   Negative for chest pain, palpitations or paroxysmal nocturnal dyspnea.  
RESPIRATORY:  Positive for frequent wheezing.   Negative for recent cough or dyspnea.  
GASTROINTESTINAL:  Positive for constipation and heartburn.   Negative for abdominal pain, abdominal bloating, diarrhea, nausea or vomiting.  
MUSCULOSKELETAL:  Positive for arthralgias, back pain and myalgias.  
INTEGUMENTARY/BREAST:  Negative for atypical moles, dry skin, pruritis, rashes, breast masses, and nipple discharge.  
NEUROLOGICAL:  Positive for ataxia, dizziness, memory loss, tremor, vertigo and weakness.  
HEMATOLOGIC/LYMPHATIC:  Positive for easy bruising.  
PSYCHIATRIC:  Negative for anxiety, depression, and sleep disturbances.  

Past Medical History / Family History / Social History: 

Past Medical History: 

Coronary Artery Disease
Hypertension 
Hypothyroidism 

Surgical History: 

Positive for
Hysterectomy; 
Positive for
Joint Replacement:
Knee Replacement: Summer 2007 right, left previously; ; ; 
Positive for Pacemaker placed July 2007; 

Family History: 

Positive for Myocardial Infarction ( father; brother -- her father and both brothers all died at age 56 from heart attacks ).  

Current Problems: 
CHF 
Degenerative arthritis of knee 
Essential hypertension, benign 
Fatigue 
Hypothyroidism 
Morbid obesity 
Obstructive sleep apnea (adult) (pediatric) 
Varicose veins of lower extremities, with Pain 

Immunizations: 
None

Allergies: 
Radiographic Dyes/Iodine:

Current Medications: 
Synthroid 0.075mg Tablet Take 1 tablet(s) by mouth daily 
Prozac 10mg Capsules Take 1 capsule(s) by mouth daily 
Spironolactone 50mg Tablet Take 1 tablet(s) by mouth bid 
Furosemide 20mg Tablets Take 1 tablet(s) by mouth daily 
Klor-Con 10 Tablets, Extended Release Take 1 tablet(s) by mouth daily 
Lasix 40mg Tablet Take 1 tablet(s) by mouth bid 
Micro-K 8mEq Capsules, Extended Release Take 1 cap by mouth daily 
Prinivil 5mg Tablet Take 1 tablet(s) by mouth daily 
Toprol XL 100mg Tablets, Extended Release Take 1 tablet(s) by mouth daily 
Oxybutynin Chloride 5mg Tablet Take 1 tablet(s) by mouth bid 
one day mult vitamin daily 

OBJECTIVE:

Vitals: 

Current: 10/21/2008 3:51:35 PM
Ht: 64 inches;  Wt: 245 lbs;  BMI: 42.05
T: 98.2 F (oral);  BP: 134/72 mm Hg (left arm, sitting);  P: 61 bpm (left arm (BP Cuff), sitting);  R: 20 bpm

Exams: 

GENERAL: morbidly obese; well groomed; no apparent distress 
EYES: pale;  EOMI; 
E/N/T: normal external ears and nose;;  Ears: both TMs are obscured by cerumen;  Hearing Screen: Able to hear fingers rubbed together with both ears;  Nasal Septum/Mucosa: partially obscured by clear drainage;  Oropharynx: normal mucosa; Post nasal drip; After irrigation the left TM is normal, the right canal is red and the TM is slightly bulging and red around the edges.  Patient states it is painful. 
NECK: Neck is supple with full range of motion; 
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs; 
CARDIOVASCULAR: normal rate; regular rhythm; normal S1 and S2 heartsounds with no S3 or S4; a systolic murmur is noted: it is grade 3/6; ; 
LYMPHATIC: no enlargement of cervical nodes; 
MUSCULOSKELETAL: gait: ambulatory with walker; 
PSYCHIATRIC: mental status: alert and oriented x 3; appropriate affect and demeanor; good insight and judgement; 

Procedures: 
Cerumen impaction 

Procedure: Cerumen impaction is noted in both ears.  The degree of wax accumulation is moderate in the left ear and right ear.  With moderate dificulty, using a syringe irrigation, the wax is removed.  Removed from ear was hard balls of wax.  The patient tolerated the procedure well.  
There were no complications.  


ASSESSMENT: 

388.71	    Otalgia, otogenic origin 
381.01	    Acute serous otitis media 
380.4	    Cerumen impaction 
477.9	    Allergic rhinitis, NOS 

PLAN: 

 Otalgia, otogenic origin 

FOLLOW-UP: Advised to call if there is no improvement 2 days.  

  Prescriptions: 
  Tramadol 50mg Tablet one po q 6 hrs, prn for pain  #12 (Twelve) tablet(s) Refills: 0 

 Acute serous otitis media 

  Prescriptions: 
  Azithromycin 250mg Tablet Take 2 tablet(s) by mouth on day 1 then 1 tablet every day for the next 4 days.  #6 (Six) tablet(s) Refills: 0 
  Floxin Otic 0.3% Otic Solution Instill 5 drop(s) in affected ear(s) daily for 7 days  #1 (One) 5 ml bottle Refills: 0 

 Cerumen impaction 

  Orders: 
     Removal impacted cerumen, one or both ears  
            A4550  Surgical trays (x1) 

 Allergic rhinitis, NOS 

IMMUNIZATIONS given today: Immunization admin., each additional > 3 y/o and Influenza.  

  Prescriptions: 
  Samples: Nasonex 50mcg/actuation Nasal Spray 2 spray(s) in each nostril daily quantity: 1 lot #: 8 MAA 33 

  Orders: 
     Immunization administration; each additional vaccine/toxoid > 8 y/o  
     Influenza virus vaccine, split virus, for use in individuals 3 years of age  and above, for intramus  


Patient Recommendations:

For  Otalgia, otogenic origin: 
Follow-up by phone if no improvement in 2 days.  


CHARGE CAPTURE: 

Primary Diagnosis: 
388.71	    Otalgia, otogenic origin 

                   Orders:
                    99214-25  Office/outpatient visit; established patient, level 4  

381.01	    Acute serous otitis media 

380.4	    Cerumen impaction 

                   Orders:
                    69210  Removal impacted cerumen, one or both ears  
                              A4550  Surgical trays (x1) 

477.9	    Allergic rhinitis, NOS 

                   Orders:
                    90472  Immunization administration; each additional vaccine/toxoid > 8 y/o  
                    90658  Influenza virus vaccine, split virus, for use in individuals 3 years of age  and above, for intramus


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## Kris Cuddy

Kristie,

2008 Coders Desk Reference cites 69210 as, "_Under direct visualization, the physician removes cerumen (ear wax) using suction, a cerumen spoon or delicate forceps. If no infection is present, the ear canal may be irrigated_."

The physician or non-physician provider, aka Nurse Practioner, Physician Assistant, Certified Nurse Midwife, must be the one to perform the removal. Irrigation is the last step of the procedure as long as there is no infection.

Unless I missed something while reading, another concern is the documentation does not tell that the M.A. did the cerumen impaction removal. Whoever is doing, aka 'providing', the service must be the one to document and sign off for their portion. It might be in your practices best interest to advise the EMR developer of this concern.

If the physician him/herself does not perform cerumen impaction removal *using instrumentation, *it cannot be billed. If you'd like me to email the attachments that won't post here, I'd be glad to do so.


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## dmaec

I'm wanted to comment on the flu vaccine given - 
81 year old, (I'm assuming she's on Medicare) the administration code for the flu vaccine should be G0008 (not 90472) .
that being said, ... even if she wasn't on Medicare - why do you have a 90472?  - shouldn't it be a 90471 (non medicare).  I don't see any other vaccine given - just the flu - (unless I missed it) so why would you use the "each additional" code for the administration of it?
just curious...
thanks!

oh, and I will say - I wouldn't be billing/charging out the cerumen removal - to me, the documentation does not support it.  appears to be irrigation to me.
{just my opinion}


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## Kris Cuddy

Donna,

If this EMR is like some I'm familiar with, hehe, it depends on how the CPT's are set up in the system as to what's available to the provider. Even if it goes into the 'billing cycle', it probably get's edited by a biller or coder who makes the appropriate changes.

Good eye on that one! We all need to keep on our toes and not completely rely on EMR for codes.


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## MJ4ever

The simplest way it was explained to me, that to compare an ear irrigation with rinsing of a skin wound. You are not able to bill that as a procedure either. 
Your note states irrigation only, so it would be no.
It took me some frustration to get over this, but if you look at it as flushing a wound it kind of makes sense.
The provider has to use tool to remove the impacte cerumen.


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## MsMaddy

Just to make sure, ear lavage by nurse only is not to be billed?

Thanks 

MsMaddy


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## mkj2486

It is my understanding that ear lavage by anyone is not billed, it is included in the E/M.  Instruments must be used for cerumen impaction removal in order to bill it and it must be done by the physician, etc.  We also require that the time it took for the procedure to be done is documented as well.


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## Lisa Bledsoe

Another point, you can't bill Medicare for surgical supplies/trays.


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## jackjones62

Also note, Medicare only pays 69210 one time per year; documentation must indicate that the wax was impacted, time involved, etc... simply removing wax with a currette does not constitute impacted wax removal, most of the time microscopy is involved due to the difficulty of the procedure.  I am not sure of what type of "surgical tray" would be required with wax removal but it is not a reimburseable item unless you list everything you use on the tray.

JB
ENT - CT


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## Kris Cuddy

JB,

Perhaps 69210 being covered only once per year is per the specific Medicare carrier. 

In Michigan, we do not have a frequency limitation on cerumen impaction removal. 69210 is covered as much as needed.


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## KristieStokesCPC

Thank you all. I have talked with the providers to explain everything. Also to comment, I do know that Medicare will not pay for the supplies and I know that the note reflects 90472 - that was a mistake on the PA's imput which I did correct before it was billed out. I have to double check everything before it gets sent out because we are on EMR and the codes plugged into the patient's note is not always the right one. 


Thank you all!


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## ChrissyMiodrag

When the procedure is done by the doctor, with the instrument, can he bill the e/m service (with 25 modifier) and the 69210, using the same ICD code? 
Thanks
Chrissy


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## Lisa Bledsoe

Chrissy - yes to your scenario.
Lisa


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## Kris Cuddy

Chrissy,

As long as the E/M was medically necessary, then yes, the doctor may bill the E/M and the 69210 performed by him/her with instrumentation.

Kris


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## cedwards1

Can you please send me the article. We always have questions about this in my office. Thanks so much! My email is cbedwards@hotmail.com
Cheri Edwards, CPC


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## Kris Cuddy

Yes, will send today.


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## dbarker

I have a question about this.  If the patient comes in for a med check/discuss labs type of thing....and then while she was there, mentioned that she felt her ear was "plugged".  The physician finds that it is cerumen impaction and then the nurse enters and does the removal.  Can you bill a regular E&M such as 99213 with the dx of HTN (or whatever) and then a 99212 for the procedure using a 25 modifier and cerumen impaction as the dx for that?  I realize there would have to be documentation to support it.


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## Kris Cuddy

> I have a question about this. If the patient comes in for a med check/discuss labs type of thing....and then while she was there, mentioned that she felt her ear was "plugged". The physician finds that it is cerumen impaction and then the nurse enters and does the removal. Can you bill a regular E&M such as 99213 with the dx of HTN (or whatever) and then a 99212 for the procedure using a 25 modifier and cerumen impaction as the dx for that? I realize there would have to be documentation to support it.


 
Unfortunately, only one E/M office visit service may be billed at each date of service. The nurse/ancillary staff performing the ear irrigation (presumably), should document his/her services and the outcome into the chart note. The provider who performed the E/M, or the coder, would then use that documentation along with the provider's documentation to determine one single E/M level for the entire visit.

Now, if the cerumen is so impacted that the provider has to remove it with instrumentation and not by irrigation, then the provider should document the removal and the outcome. Then, there would be appropriate documentation for the 69210 for the cerumen impaction removal.

Does this make sense and/or help?


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## dbarker

Yes....makes sense.  Thanks so much


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## Kris Cuddy

You are welcome anytime.


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## dbarker

So, I have another question now.  If someone is referred to our clinic for an ear wash or even removal by instrumentation and the nurse does it.......if the documentation is there, would it be appropriate to charge a 99212 (minimal) and not the procedure?  It is a nurse visit after all.


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## dbarker

Woops!  I meant to put 99211 as the E&M...not 99212 on that last entry.


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## Kris Cuddy

dbarker said:


> So, I have another question now. If someone is referred to our clinic for an ear wash or even removal by instrumentation and the nurse does it.......if the documentation is there, would it be appropriate to charge a 99212 (minimal) and not the procedure? It is a nurse visit after all.


 
Ok, understanding you changed the 99212 to a 99211 in a second email.

The first question we need to look at is whether it is in RN, LPN, or MA scope of practice in your state allows their licensure to perform cerumen impaction removal using instrumentation.

Do you have your state's scope of practice available?


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## dbarker

We are in Illinois and that services is allowed.  Basically my question is just asking as to whether we could charge a nurse E&M if she does this service.  We wouldn't be charging for the earwash itself.....only the minimal E&M.


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## FTessaBartels

*E/M only*

If no instrumentation is used, but there is an ear wash you code the appropriate level E/M.

F Tessa Bartels, CPC, CEMC


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## Kris Cuddy

dbarker said:


> We are in Illinois and that services is allowed. Basically my question is just asking as to whether we could charge a nurse E&M if she does this service. We wouldn't be charging for the earwash itself.....only the minimal E&M.


 
As there is no procedure code for a nurse visit, there is the minimal E&M, as you indicate in the last sentence, that could be charged if evaluation and management are performed under the doctor's direct supervision.

The direct supervision does not mean the doctor has to be in the room, however the doctor must be in the suite or office.

If chart documentation indicates the doctor ordered the patient to come for a service with the nurse and the nurse performs evaluation and management of a patient under the doctor's direct supervision and documents the evaluation and management, then yes the 99211 E&M service would be appropriate.

As a community, the term 99211 as a "nurse visit" truly is simply a slang. 99211 does not require the same components as other E&M services, however it is an evaluation and management service.

The bottom line is this in my humble opinion; if there is medical necessity, if there is documentation to support the physician ordered the service, if there is documentation of the service, then a service is billable.

Does this help?

The bottom line is,


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## csruiz

*Impacted cerumen*

How is this proceedure being coded because everytime I bill I get denials stating that it is part of the ov.(global)?  cr


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