ED Coding and Reimbursement Alert

Question: Documentation states that the physician personally removed a small portion of impacted cerumen with a curette. However, she could not remove the rest of the cerumen because it was too hard. The guideline states she should document how much time and the resources used to remove the cerumen. Should we code 69210 with modifier 52, or just roll the work into an ED E/M service?

Connecticut Subscriber

Answer: Code the impacted cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) and consider appending the modifier 52 (Reduced services).

Why not 53? Modifier 53 (Discontinued procedure) is for procedures that were halted due to a concern regarding a complication of patient problem. Use this guide when deciding between modifiers 52 and 53:

Use 53 when: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

Use 52 when: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced.