ED Coding and Reimbursement Alert

E/M-25 practically a given on earwax removal encounters.

If you're keen to the guidelines governing cerumen removal claims, you'll be a boon to your practice's bottom line.

In the ED setting, a separate E/M service is almost a given when the physician provides a 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) service. That means you could miss out on money if youlet opportunities to code cerumen removal slip past you.

Caveat: If your physician removes a patient's earwax, you cannot just tab 69210 automatically, confirms Eli Berg, MD, FACEP, CEO of MRSI, an ED coding and billing company in Woburn, Mass. There are some instances when your physician's cerumen removal will not rise to a 69210 service.

Know the difference, and get your cerumen removal claims right each time, with this expert advice.

Check Notes for Instrumentation, Impaction

In order to code cerumen removal with 69210, the physician must follow some fairly strict rules with most payers, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, Manager of Compliance Education with manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

For most insurers, most 69210 claims are marked by the following:

• The physician performs manual disimpaction of cerumen
• The physician uses direct visualization during the cerumen removal
• The physician uses some sort of instrumentation during the procedure.

Often, the physician uses one of the following tools for 69210 service, Bucknam confirms:

• suction,
• probes,
• forceps,
• curettes,
• otoscope,
• right angle hooks.

Caveat: Some of Bucknam's payers have suggested that they would pay 69210 for disimpaction by irrigation when there are no signs of inflammation. However, Bucknam warns against coding 69210 for earwax removal via irrigation unless you are absolutely sure the payer accepts it.

"This is contrary to CPT and I would not do it unless I had written information from the payer that it was covered," she says.

Coders should also be sure that the physician has removed impacted cerumen from the ear canal before choosing 69210, Berg reminds.

Breakdown: "Non-impacted cerumen is a normal part of the ear physiology. It can become impacted when people press the cerumen into the ear canal," explains Bucknam.

Caveat: Some of Bucknam's payers have suggested that they would pay 69210 for disimpaction by irrigation when there are no signs of inflammation. However, Bucknam warns against coding 69210 for earwax removal via irrigation unless you are absolutely sure the payer accepts it.

"This is contrary to CPT and I would not do it unless I had written information from the payer that it was covered," she says. Coders should also be sure that the physician has removed impacted cerumen from the ear canal before choosing 69210, Berg reminds.

Breakdown: "Non-impacted cerumen is a normal part of the ear physiology. It can become impacted when people press the cerumen into the ear canal," explains Bucknam.

Use Clinical Example for Greater 69210 Understanding

Check out this detailed clinical example, courtesy of Bucknam:

For this 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 and 99282 to represent the patient's cerumen impaction

Note: "Modifier 50 [Bilateral procedure] is not appropriate [in this scenario] as 69210 applies to one or both ears," reminds Bucknam.

Spot Separate E/M for Max Money

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

The lowdown: Consider the above example, in which  the coder reports 69210 and 99282-25. Let's say you only report 69210, and fail to identify the 99282 service.

The 69210 code pays about $32 per encounter (0.96 adjusted facility relative value units [RVUs] multiplied by the 2011 Medicare Physician Fee Schedule conversion rate of 33.9764). Further, 99282 pays about $40 per encounter (1.19 adjusted facility RVUs multiplied by 33.9764). Identifying the separate E/M in this instance will more than double your money for the same claim.

There are other earwax removal encounters, however, that will not allow for 69210 and an ED E/M service.

E/M Service Might Flush Out the Wax

If the provider removes cerumen that is not impacted without using any of the aforementioned instrumentation, you should only report the appropriate level E/M instead of 69210, Bucknam confirms.

The basics: "Non impacted cerumen is typically soft, easily removed and is more of a routine part of the [E/M] physical exam," Berg explains.

Example: A patient reports to the ED complaining of right ear pain. During a problem focused history and exam, the nonphysician practitioner (NPP) examines the ear, and notes that the tympanic membrane (TM) is obscured by some soft wax that he removes with a cotton swab. The TM is then visualized, and the ED physician notes it is inflamed, consistent with a middle ear infection. The physician prescribes an antibiotic and discharges the patient.

Since the NPP removed non-impacted soft cerumen without the aid of visualization or specific instrumentation, you would report 99283 (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 moderate complexity ...) for the entire encounter.