# 99214 and 69210



## tarafarmer (Sep 29, 2009)

Can you tell me if it is appropriate to bill a 99214 and 69210 when the patient presents to the office with impacted cerumen? The doc did a complete history, and exam. The cerumen impaction is noted as resolved.


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## mitchellde (Sep 29, 2009)

Is there a procedure note for the 69210?


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## tarafarmer (Sep 29, 2009)

Actually regarding the 69210, the only thing that is stated is bilateral ear lavage completed.


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## mitchellde (Sep 29, 2009)

69210 is not a code for an ear lavage, it is a procedure performed by the physician which necessitates the use of a scoop or a currette.  So in this case it is an ov only.


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## tarafarmer (Sep 29, 2009)

According to the Emergency Medicine Coding Companion, if ther is no infection present, the ear canal may then be irrigated.


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## FTessaBartels (Sep 29, 2009)

*Ear irrigation is NOT removal of impactged cerumen*

There are several threads on this forum regarding this topic.

NO, you may NOT code 69210 for ear irrigation. 

All you have is an office visit. 

F Tessa Bartels, CPC, CEMC


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## tarafarmer (Sep 29, 2009)

According to what I am reading here in the coding companion, I don't understand why I do not have 69210 when it specifically states "If no infection is present, the ear canal may then be irrigated." Please help me understand why I can not bill that.


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## mitchellde (Sep 29, 2009)

I am not sure what context that passage is written in, but an ear irrigation is simply part of the visit level, irrigation uses a water jet, the 69210 as stated earlier uses a scoop or a currette and must have a procedure note by the physician.


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## tarafarmer (Sep 29, 2009)

If you would like, I can forward a copy of the page from the coding companion, and you could take a look at what I am reading.


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## mitchellde (Sep 29, 2009)

that would be great, my e-mail is debraawm@yahoo.com.  I am leaving here in a few but will look at it as soon as I can.  Thanks!


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## mitchellde (Sep 29, 2009)

Upside down was good!  Anyway I do believe it is badly written, I believe they are telling you that if there is no infection then it is an irrigation and not an impacted cerumen removal.  It is unfortunate that this is written in this fashion, however it is still not billable as a 69210 if it is an irrigation only.


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## tarafarmer (Sep 29, 2009)

Debra,
I very much appreciate your help, and I am not trying to belabor the point, but did you notice at the top it states, "The wax is extracted with a cerumen spoon or delicate forceps or by irrigation." When my doctors come to me, and we have this as a source I am going to need something that will substantiate that I cannot bill this as a procedure. I will tell you that that for years I have held the same view that you are stating, but the wording in this coding companion is causing me to question which is more accurate. I have used the companion to back up other issues I have had, and for me to tell them that we cannot bill this I am going to need something pretty creditable. Being in the field, I am sure you can understand my dilemma. Can you give me another source to use?


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## mitchellde (Sep 29, 2009)

I am pretty sure there is a CPT assistant on this and I think a Med learn as well.  Unfortunately there are several sources of information out there that are not altogether correct and it does provide numerous problems.  I cannot imagine where Ingenix was going with this.  I will go thru my sources and see what references I can come up with since I know I have run upon this before.  I will get back to you.


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## tarafarmer (Sep 29, 2009)

Thank you, I do appreciate that.


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## RebeccaWoodward* (Sep 29, 2009)

Per CPT Assistant July 2005...

In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), we present the following discussion which provides some typical coding scenarios with regard to the appropriate use and application of CPT codes related to ear wax removal:

*1.The patient presents to the office for the removal of “ear wax” by the nurse via irrigation or lavage.*
*2.The patient presents to the office for the removal of “ear wax” by the primary care physician via irrigation or lavage.*
3.The patient presents to the office for “ear wax” removal as the presenting complaint. This is described as impacted cerumen because it completely covers the eardrum and the patient has hearing loss. The impacted cerumen is removed by the primary care physician or otolaryngologist with magnification provided by an otoscope or operating microscope and instruments such as wax curettes, forceps, and suction.
Question

Are these procedures appropriately reported with CPT code 69210, Removal impacted cerumen (separate procedure), one or both ears?

AMA Comment

A major element in determining whether code 69210 should be reported is understanding the definition of impacted cerumen. By definition of the AAO-HNS,

“If any one or more of the following are present, cerumen should be considered ‘impacted’ clinically:

•Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.
•Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.
•Inflammatory considerations: Associated with foul odor, infection, or dermatitis.
•Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.”
Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting of CPT code 69210. Rather, that work would appropriately be captured by an evaluation and management (E/M) code regardless of how it is removed. If, however, the wax is truly impacted, then its removal should be reported with 69210 if performed by a physician using at minimum an otoscope and instruments such as wax curettes or, in the case of many otolaryngologists, with an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angles). Accompanying documentation should indicate the time, effort, and equipment required to provide the service. Add-on code 69990, Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure), should not be reported if the operating microscope is used for cerumen removal. In this later instance, however, code 92504, Binocular microscopy (separate diagnostic procedure), may be reported.

Therefore, based on this information, *scenarios 1 *and* 2* would not be reported with code 69210. These scenarios would be captured by the appropriate E/M code. Scenario 3, however, should be reported with code 69210 because both criteria were met; the patient had cerumen impaction and the removal required physician work using at least an otoscope and instrumentation rather than simple lavage.


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## KKayWilson (Sep 29, 2009)

*it seems there are quite a few ENT coders out there*

I work for two ENTs.  We code the E/M level visit, then code 69210 for removal of impacted ear wax with modifier.  The physician has to code for his encounter to arrive at the problem by ROS, examination of pt. presenting problem.
We are getting paid.

your fellow coder
k


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## mitchellde (Sep 30, 2009)

rebeccawoodward said:


> Per CPT Assistant July 2005...
> 
> In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), we present the following discussion which provides some typical coding scenarios with regard to the appropriate use and application of CPT codes related to ear wax removal:
> 
> ...



Thanks Rebecca I somehow knew you would have instant access to this, I knew it was there but I have to go to a different database to get it, thank you for getting there more quickly.


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## tarafarmer (Oct 2, 2009)

Thank you for the information. I do really appreicate it.


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