ED Coding and Reimbursement Alert

Listen up, coders: Patients reporting to the ED for removal of earwax exist on the fault line between ED E/M service and procedure code. Knowing the difference could net you about $30 more per claim.

Check out these clues for help making the decision between a procedure code and an E/M on your earwax encounters.

It might seem like a slam dunk: Patient reports to the ED with earwax, provider removes it, and coder chooses cerumen removal code ... right?

Wrong: Some earwax extraction encounters will not reach the procedure level. In order to report a cerumen removal code, the provider has to use direct visualization (via otoscope) to remove impacted cerumen, says Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists PC in Grand Rapids, Mich.

The methods most commonly employed for cerumen disimpaction are suction, probes, forceps, right angle hooks, and curettes.

Definition: Payers consider cerumen clinically impacted "when it impairs the exam of a clinically significant portion of an external auditory canal, tympanic membrane, or middle ear condition," explains Jamie Darling, CPC, coder at EA Health Corp. in Solana Beach, Calif. "Impacted cerumen is obstructive and can't be removed without a physician's time and skill," she says.

Example: A child reports to the ED complaining of fever and upper respiratory infection symptoms. While checking for an ear infection, the physician uses an otoscope for visualization and determines that the patient has soft earwax in his outer ear. The physician removes a small amount of soft earwax with a single scoop of the curette. Ultimately, the child is diagnosed with tonsillitis and discharged home.

In this instance, the physician did not remove impacted cerumen -- the removal was part of the ear exam. Therefore, you should code the encounter with the appropriate-level E/M code, such as 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; and medical decision making of low complexity ...).

Payout: For the above scenario, you'll net about $40 (1.09 transitioned facility relative value units [RVUs] multiplied by the 2009 Medicare conversion rate of 36.0666)

If you cannot identify legitimate potential impacted cerumen removals, missed money will add up fast, as you lose a chance to report an ED E/M and 69210 (Removal impacted cerumen [separate procedure], 1 or both ears).

Patients who report to the ED for 69210 will almost always require an E/M service before the procedure, Pinckney says.

Example: A patient reports to the ED complaining of hearing loss and a malodorous yellow fluid hardening inside his left eardrum. The ED physician uses an otoscope to try and visualize the tympanic membrane, but it is blocked by cerumen. The physician diagnoses.