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Remember the rules for procedure coding on these common services.

Sometimes, how you code a treatment depends on how extensive the treatment is.

Explanation: Certain encounters for specific conditions might start and end with an emergency department (ED) evaluation and management (E/M) service. However, other encounters for those very same conditions can involve a procedure and an ED E/M. It all depends on the time, knowledge, and instrumentation the ED physician uses to repair the defect.

Check out this advice on a pair of common ED presentations: impacted cerumen and epistaxis, colloquially known as earwax and nosebleeds.

E/M Will Lead Off Any Epistaxis Claim

Patients who end up needing cerumen removed from their ears can present with a variety of symptoms, including hearing loss and earache. From there, the ED physician will decide if the patient has impacted cerumen.

When a patient reports to the ED with complaints like hearing loss or earache, the ED physician will often discover cerumen upon performing an E/M service. The physician will likely use an otoscope to determine if the patient has cerumen and if it is impacted.

If the physician removes non-impacted cerumen, you’ll roll the work into the overall ED E/M service, then choose a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set. 

“Non-impacted cerumen removal is part of the E/M service,” explained Dottie Davis, CPMA, CPC, COC, CGSC, CEMC during a HEALTHCON Regional 2024 presentation in Philadelphia.

When the physician removes non-impacted cerumen, they’ll often wipe the cerumen away with a damp cloth or cotton ball. During these removals, there is no use of instrumentation or irrigation.

Know Impacted Removal Methods, Codes

When the ED physician removes impacted cerumen, you have two code choices. The proper code will depend on the method of cerumen removal.

When the physician removes impacted cerumen using irrigation or lavage, report 69209 (Removal impacted cerumen using irrigation/lavage, unilateral). The physician might use a gentle stream of warm water to excavate the cerumen; they might also use a syringe or electronic irrigation device.

When the physician removes impacted cerumen using instrumentation, report 69210 (Removal impacted cerumen requiring instrumentation, unilateral). The instrumentation the physician might be one of the following:

• Curettes: These are spoon-shaped tools that physicians use to scoop out cerumen
• Scalpel: The physician might use this tool to carefully cut the cerumen out
• Suction devices: These tools utilize suction to extract the cerumen
• Microsuction: The physician will use a microscope to visualize the affected area, then use a suction device to extract the cerumen

Remember: If the physician performs 69209 or 69210 service, you’ll also be able to report an ED E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended. Just make sure the notes clearly indicate that the ED E/M and cerumen removal were significant, separately identifiable services.

Use These Dx Codes for 69209, 69210

The descriptors for 69209 and 69210 specifically state “impacted cerumen”; therefore, the patient must have an impacted cerumen diagnosis in order to report these codes. These are the only ICD-10 codes for impacted cerumen:

• H61.20 (Impacted cerumen, unspecified ear)
• H61.21 (Impacted cerumen, right ear)
• H61.20 (Impacted cerumen, left ear)
• H61.20 (Impacted cerumen, bilateral)

Follow Similar E/M Procedure Protocols for Epistaxis

Much like cerumen removal, stopping nosebleeds can range from very simple to a bit more complicated in the ED. Also, like cerumen removal, the ED E/M will light the way toward epistaxis treatment.

During the initial ED E/M, a patient with a nosebleed will be evaluated by the physician. If they don’t use cautery or packing to stop the bleeding during the encounter, you’ll roll the work into the overall ED E/M level when you choose a code from the 99281- 99285 code set.

Methods can vary on these nosebleed stops. “If the physician controls the bleeding by applying external pressure, and also uses a cotton swab with phenylephrine and removed right after, then this would be included in the E/M service,” explains Marco Unzueta, BSHIM, CPC, CCS, CIC, CDEO, CDEI, AAPC Approved Instructor, medical coding supervisor at El Paso Children’s Hospital in El Paso, Texas.

Other conservative treatments that would be considered part of the E/M service include application of ice and use of gauze to stop the bleeding.

Use These Codes for Nosebleed Repair

You’ll report most epistaxis repairs that extend beyond an ED E/M with one of the following codes:

• 30901 (Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method)
• 30903 (Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method)

For a 30901 repair, the ED physician will use electrical or chemical coagulation or packing materials to the front section of the nose. These repairs are marked by a “limited” use of coagulation or packing methods.

For a 30903 repair, there could be a number of elements that raise the repair from simple to complex. It could be that the repair extended deeper into the nasal canal, or that the physician had to perform multiple coagulations. If there are additional layers of packing, it might also rise to a 30903 repair level.

Posterior Bleed? There Are Codes for That

CPT^® has also included separate codes for nosebleeds that occur in the posterior portion of the nose. Be careful with these codes, because the reporting rules are different.

When a patient reports with a posterior nosebleed, you’ll typically report 30905 (Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial) or 30906 (… subsequent). You’ll notice that these codes don’t have the simple and complex definitions of the anterior epistaxis repairs. This means that you’ll only be concerned whether the anterior repair was initial or subsequent.

Do this: If the provider is treating a posterior bleed for a patient for the first time, go with 30905. If encounter notes indicate that the fix is for a repeat posterior cautery and/or packing, submit 30906.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC