ED Coding and Reimbursement Alert

When a patient reports to the ED for removal of impacted cerumen, be on the lookout for evidence of a separately codeable E/M service.

In the ED setting, the physician nearly always provides a separate E/M for patients who require a 69210 (Removal impacted cerumen [separate procedure], one or both ears) service, says Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists PC in Grand Rapids, Mich.

Definition: According to article A44326, "Removal of Impacted Cerumen and Evaluation and Management Services" from-the Medicare Local Coverage Determination (LCD) for Alabama, Georgia and Mississippi: "If a separate, identifiable evaluation and management service is provided during the same visit, then Medicare may cover an evaluation service if modifier 25 is added to the evaluation and management CPT code, indicating that the evaluation and management service was unrelated to the cerumen removal procedure."

Check out these coding examples to better understand when you can report an E/M service and 69210 for the same encounter:

Example 1: A patient comes to the ED complaining of a headache. During the course of a level-three E/M, the ED physician decides the headache is from chronic sinusitis. During the E/M, the physician notices impacted cerumen in the patient's left ear, which he removes using a curette and otoscope.

In this scenario, the ED physician performed an E/M service to address the headache and then removed impacted cerumen. On the claim, report the following:

- 69210 for the cerumen removal

- 380.4 (Impacted cerumen) linked to 69210 to represent the impacted cerumen

- 99283 (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 moderate 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 99283 to show that the E/M and cerumen removal were separate services

- 473.9 (Unspecified sinusitis [chronic]) and 784.0 (Headache) linked to 99283 to represent the patient's sinus infection and headache.

You can also report a separate E/M when the physician performs and documents the elements of an E/M service while identifying the impacted cerumen.

Example 2: A patient presents with trouble hearing in the right ear (the patient says her hearing has gotten progressively worse in the last week). The physician performs an expanded problem-focused history and expanded problem-focused exam, including a check of both ears with an otoscope.

Upon examination, the physician determines that the problem is a massive cerumen impaction filling the entire external auditory canal and covering the eardrum.

The physician proceeds to remove the impacted cerumen with otoscope magnification, forceps and suction. After the removal, the physician examines the external auditory canal and tympanic membrane. He then counsels the patient on cerumen management strategies.

In this scenario, the physician provided an E/M service that was significant and separately identifiable before deciding to perform impacted cerumen removal. On the claim, report the following:

- 69210 for the cerumen removal

- 99282 for the E/M

- modifier 25 linked to 99282 to show that the E/M and procedure were separate services.

- 380.4 linked to 69210 and 99282 to prove medical necessity for the services.