ED Coding and Reimbursement Alert

Patients who require cerumen (earwax) removal can clog up your coding continuity if you-re not careful to identify the type of cerumen the physician treats. When an ED provider removes non-impacted cerumen, you should consider the removal an E/M service.

On the other hand, if the provider removes impacted cerumen, you will likely choose a CPT code instead. Check out this primer on identifying impacted cerumen claims.

The key to proper code choice for cerumen removal lies with the diagnosis and the provider's actions during the encounter. If the physician removes impacted cerumen with instrumentation, you can report 69210 (Removal impacted cerumen [separate procedure], one or both ears) for the service, says Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists PC in Grand Rapids, Mich.

"Impacted" definition: For coding purposes, "impacted" cerumen is earwax that "impairs the exam of a clinically significant portion of an external auditory canal, tympanic membrane or middle ear condition," says Jamie Darling, CPC, coder at EA Health Corp. in Solana Beach, Calif. This cerumen is usually extremely hard and dry, and often causes the patient pain or itching. It may also have a foul odor or cause infection, Darling says.

"So we aren't talking about the kind of earwax a nurse can flush out easily prior to an exam," Darling says.

According to Pinckney, if the physician uses one of the following instruments to remove impacted cerumen, the service likely qualifies for 69210:

- suction

- probes

- forceps

- right angle hooks

- wax curettes.

You should use these criteria as a base, but different carriers may have different policies on cerumen removal. The commonality is that the ear is impacted with cerumen and the provider performs removal by means other than simple lavage, involving a significant process. You-ll also have to prove medical necessity and include the proper documentation for your 69210 claim to be successful, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Falbo offers this guidance from Pennsylvania Medicare. According to the carrier, payment for removal of impacted cerumen is allowable when the encounter meets the following conditions:

- the service is the sole reason for the patient encounter,

- the service is performed by a physician or non-physician practitioner (i.e., nurse practitioner, physician assistant, clinical nurse specialist),

- the provider shows that the patient has impacted cerumen symptoms, and

- the documentation illustrates significant time and effort spent in performing the service.

Example: A patient presents with problems in his right ear. He says there has been constant ringing in the ear and severe itching in the canal for three days.

The ED physician checks the patient's left ear, which is clear. A right-ear check reveals extreme canal blockage by crusty hard wax. Due to the obstruction, the physician cannot see the tympanic membrane. She removes a large piece of impacted cerumen using an earwax curette, suction and otoscope with a large speculum.

On the claim, you should report 69210. Also, attach 380.4 (Impacted cerumen) to 69210 to prove medical necessity for the visit.

For some carriers, 380.4 is the only acceptable ICD-9 code to support reporting 69210. According to LCD 1597 for Tennessee's Riverbend GBA, for example, the only diagnosis that supports medical necessity is 380.4.

However, there are other carriers that are more lenient on 69210 diagnosis coding.

Kansas Medicare LCD L9422 has 100 different diagnoses that support medical necessity for 69210.

Best bet: Check your individual contracts for specific information on proving medical necessity for 69210.

When the provider removes cerumen without instrumentation, you will likely have to consider the removal a part of the overall E/M service and code accordingly, Darling says.

These cerumen removal encounters will likely result in a low-level E/M, depending on the encounter specifics. Suppose the ED physician evaluates an established patient's ear, and removes a small amount of wax with lavage and cotton swabs. The ED physician diagnoses otitis media and places the patient on antibiotics to treat the infection. Notes indicate a level-two E/M.

On the claim, report 99282 (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 low complexity) for the cerumen removal. Remember to link ICD-9 code 382.9 (Unspecified otitis media) to 99282 to represent the patient's ear pain.