ED Coding and Reimbursement Alert

Why you’ll get denied if you report 69210 more than once per episode.

Patients often present to the ED with complaints of ear discomfort, a feeling of pressure and sometimes hearing loss. They may think they have an ear infection but upon examination, impact ear wax or cerumen is the actual cause of their complaints. Varying payer payment policy makes cerumen removals tricky to report.

To prevent your appeals from falling on deaf ears, follow these four coding tips from Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates in Baton Rouge LA

1. Assign 69210 only when the physician extracts impacted earwax. Typically, the physician uses mechanical means, such as debridement or manual disimpaction, to remove the cerumen. Remember to check your carrier’s guidelines for which removal method justifies billing 69210 (Removal impacted cerumen [separate procedure], one or both ears). But when the physician can easily take out the wax as part of the routine ear exam, then this small level of effort might best be rolled into the E/M code.

2. Report 69210 once per session, even if the physician removes impacted cerumen from both ears. The code’s descriptor states that 69210 covers cerumen removal from “... one or both ears”, so no modifier 50 (Bilateral procedure) would be appended.

3. Be sure you link 380.4 (Impacted cerumen) to 69210. Most private and Medicare insurers will not accept any other ICD-9 codes, even if the codes describe a hearing-related problem. For example, you shouldn’t use 389.x (Hearing loss) or 381.81 (Dysfunction of Eustachian tube).

4. Check your carrier’s coding restrictions for cerumen removals. For example, some regions, pay for 69210 only when the physician removes the impacted cerumen using the manual disimpaction method specifically mentioning using an instrument such as forceps, suction or a right-angle hook.

Let This Clinical Example Guide You

Edelberg provides this example:

A patient presents to the ED complaining of discomfort in his right ear which is worse when swallowing.  During an expanded problem focused history and examination, the physician discovers cerumen impacted in the right ear and notes indicate that the eardrums cannot be visualized.  The physician uses a curette to remove the impacted cerumen, which immediately improves the patient’s hearing and removes the discomfort. 

The physician then re-examines the ears and finds no signs of disease or damage to the eardrums. The physician diagnoses the patient with impacted cerumen and then counsels the patient against putting anything in the ears that would impact the cerumen again.

On the claim, you would report the following:

69210 for the cerumen removal

99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the E/M service

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and cerumen removal were separate services

380.4 (Impacted cerumen)  appended to 69210 to represent the patient’s cerumen impaction

388.70 (Otalgia, unspecified) to 99282 to represent the patient’s ear pain

Don’t Forget the E/M Code If Documentation Supports That Service

When you do spot a legitimate 69210 claim, remember to check for adequate documentation to support a separately identifiable E/M service or you’ll miss out on deserved reimbursement.

$$ benefits with E/M: The 69210 code pays $32.66 per encounter (0.96 adjusted facility relative value units multiplied by the 2013 Medicare Physician Fee Schedule conversion rate of 34.023). But code 99282 pays $40.15 per encounter (1.18 adjusted facility RVUs multiplied by 34.023). Identifying the separate E/M in this instance will more than double your money for the same claim, says Edelberg.