ED Coding and Reimbursement Alert

Report cerumen removal with E/M if you can prove the services are separate
 
Patients who require cerumen removal services in your ED present several coding challenges: You will first have to decide if the encounter satisfies the requirements for reporting 69210 (Removal impacted cerumen [separate procedure], one or both ears). If it doesn-t, you-ll have to choose the proper evaluation and management code for the service.

But there are also instances in which the physician will remove impacted cerumen and perform a separate E/M. Coders who can identify these scenarios will help the practice by ethically reporting a pair of codes instead of one.

In fact, when an ED physician removes impacted cerumen, he-ll typically perform a separate E/M, says Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists PC in Grand Rapids, Mich.

Important: To report 69210 and a separate E/M, you-ll have to prove medical necessity for both services.   -As long as you demonstrate medical necessity and show a separate history, exam and medical decision- making, you can report an E/M- and 69210, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

But you should be absolutely sure that the reason for the office visit is separate from the ear impaction, says Steve Verno, NREMTP, CMBSI, director of reimbursement at Emergency Medicine Specialists in Hollywood, Fla.

Check out this explanation from Empire Medicare's local coverage determination (LCD): -An E/M service on the same day as removal of impacted cerumen may not be billed unless it represents and is documented to be a significant, separately identifiable service on the same day.-

Remember to Separate E/M, Removal on Your Claim

If a patient presents with impacted cerumen and also reports another symptom -- such as pain in an area other than the impacted ear -- the ED physician will perform a separate E/M for those procedures.

A separate E/M is also possible when the physician finds the impacted cerumen when examining another complaint, Cobuzzi says. -For example, if the patient has an earache and there is so much wax there the physician has to perform disimpaction to examine the ear- you should report 69210 and an E/M, she says.

Whatever the reason for the separate E/M, remember to include modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the claim or you-ll get a denial on the E/M code.
 
Consider this example from Verno: A patient presents with 3-day-old loss of hearing in her right ear, with a constant ringing in the same ear and severe itching in the canal. The patient says that the ear feels plugged, and she also complains of low back pain after lifting a heavy object. There is no direct trauma to the back, and the pain is localized to the lower back.

The physician examines the left ear, which is clear. He cannot examine the right ear because the canal contains crusty hard wax that is blocking the tympanic membrane. Examination of the back shows no redness in the lumbar region, but tenderness upon palpation in the L-2 through S-1 area. The patient also exhibits limited motion during adduction, abduction, flexion, extension and rotation. 

The physician removes a large piece of impacted cerumen using an ear curette and otoscope with large speculum. With the cerumen cleared, examination indicates the ear canal is slightly red, but the middle ear is clear.

The physician also orders x-rays of the lumbar spine, which are ultimately read as negative. In this example, the physician performed cerumen disim-paction and a separate E/M for the patient's back pain. On the claim:

- report 69210 for the disimpaction.

- link 380.4 (Impacted cerumen) to 69210 to represent the patient's cerumen.

- report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M service.

- link 846.0 (Sprains and strains of sacroiliac region; lumbosacral [joint] [ligament]) to 99283 to represent the patient's back pain.

- append modifier 25 to 99283 to show that the cerumen removal and the E/M service were for separate complaints.