ED Coding and Reimbursement Alert

Question: A young girl was recently brought into the ED with a high fever and difficulty breathing. The ED physician diagnosed pneumonia. During the exam, he also noted a great deal of impacted cerumen in both of the patient's ears. Should we report the cerumen removal and the ED visit code?

Texas Subscriber

Answer: You should probably bill both, although that might not be true in all situations.

When a patient is seen for a problem that is unrelated to the impacted earwax, many payers (including Medicare) will reimburse both services. You should report the E/M service (e.g., 99284, Emergency department visit) linked with the diagnosis or condition that prompted the visit. In this case, pneumonia (e.g., 480.2, Viral pneumonia; pneumonia due to parain-fluenza virus), fever (780.6, Fever) and breathing problems (786.05, Shortness of breath) may be used. In addition, 69210 (Removal impacted cerumen [separate procedure], one or both ears) would also be assigned, with 380.4 (Impacted cerumen). Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be added to the E/M code to indicate it was a significant and separately identifiable service.

If the reason for the ED visit is directly related to the cerumen (e.g., 388.70, Otalgia, unspecified or 388.30, Tinnitus, unspecified), the insurer will most likely pay for 69210 only.