ED Coding and Reimbursement Alert

Question: The physician documented that a patient has "wax bilaterally" and that he removed the wax by "flushing ears bilaterally." Can we report 69210 in addition to an E/M?


North Carolina Subscriber


Answer: You should use 69210 (Removal impacted cerumen [separate procedure], one or both ears) only when the physician removes "impacted" cerumen, not simple earwax blockage.

For instance, if your physician used irrigation, Cerumenex, or forceps to remove impacted cerumen, you should assign 69210. Also, you should link 380.4 (Impacted cerumen) to 69210 to show medical necessity.
 
Note: Payers vary on their guidelines regarding acceptable methods for removing impacted cerumen, so check with your carrier for specific requirements.

Remember that if the physician was able to easily remove the wax, you shouldn't report 69210. In that case, your best bet would be a low-level evaluation and management code. If you're able to use 69210 and want to bill an E/M as well, be sure the physician performed a separately identifiable service in addition to the wax removal - and attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.