ED Coding and Reimbursement Alert

E/M code is the better option when cerumen isn't impacted

If an ED physician removes cerumen from a patient's ear, coders should not just choose the impacted cerumen removal code without identifying all of the specifics of the encounter.

Why? In order to properly report 69210 (Removal impacted cerumen [separate procedure], one or both ears), you have to prove that the cerumen required instrumentation and physician involvement. For treatments that do not meet 69210 criteria, you-ll have to choose another coding strategy.

Check out this advice on when to pick 69210 -- and when another code choice is a better option.

Determine Whether Cerumen Is Impacted

When considering 69210, you first need to find evidence that your physician removed impacted cerumen with instrumentation. If he removes the cerumen without instrumentation, you cannot report 69210. -Impacted means the ear wax is packed tightly in the outer ear, so much so that the external ear canal is blocked. The ear wax is hard and possibly crusted,- says Steve Verno, NREMTP, CMBSI, director of reimbursement at Emergency Medicine Specialists in Hollywood, Fla.

Also, the physician has to perform the procedure with some type of instrumentation to report 69210, says Sandra Pinckney, CPC, coder at Certified Emergency Medicine Specialists PC in Grand Rapids, Mich.

On your 69210 claims, most carriers want to see evidence that the physician performed the disimpaction under direct visualization using one of the following methods, Pinckney says:

- suction

-  probes

-  right angle hooks

-  curettes.

You should use these criteria as a base, but -different carriers may have different policies on cerumen removal. The commonality is that the ear is impacted with cerumen and the removal is performed by means other than simple or lavage, and involves a significant process,- Verno says.

As an example, Verno notes the 69210 policy for Blue Cross-Blue Shield: -CPT code 69210 is eligible for reimbursement when the following criteria are met: The cerumen removal requires the skill of a physician, or the removal is directly supervised by a physician and the cerumen removal requires a significant amount of time and effort.-

Best bet: Check with your insurers for the specifics on their policies for 69210.

Consider this example from Verno: A patient presents with 4-day-old loss of hearing in his right ear, with associated signs of a constant ringing in the same ear and severe itching in the canal. The patient says that his right ear -feels like it is plugged.- The physician examines the left ear canal, which is clear with the tympanic membrane intact. The middle of the left ear is also clear. However, the physician is unable to examine the right ear due to extreme blockage of the canal by crusty wax. Further, she cannot visualize the tympanic membrane due to blockage.

The ED physician removes a large piece of impacted cerumen using an ear curette and otoscope with large speculum. The right ear is then re-examined; the blockage is clear, and the ear canal appears red and inflamed. The physician can now visualize the tympanic membrane, and the middle of the right ear is clear.

In this scenario, the physician satisfied the requirements for the cerumen removal code. On the claim, report 69210 for the procedure. Don't forget to link ICD-9 code 380.4 (Impacted cerumen) to 69210 to represent the impacted cerumen.

Many carriers see 380.4 as the only acceptable ICD-9 code for 69210. But check your insurers- policies to be sure because some payers will accept other diagnoses for 69210, Verno says.

-For example, Kansas Medicare has 100 different diagnoses that support medical necessity for 69210,- Verno says.
 
Opt for E/M Code When ED Physician Doesn't Perform Removal
 
So what should you do on cerumen-removal claims when you cannot find evidence of instrumentation or physician involvement? Rely on your evaluation and management codes, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Scenarios that you-d code with an E/M might involve simple irrigation with a minor amount of removal. Most carriers consider these removal methods incidental to an E/M visit, says Verno, who recommends that you check your payer policies to be sure you-re coding the cerumenremoval correctly.

Example: A 6-year-old patient reports to the ED complaining of a cold. The physician finds inflammation in the middle left ear. In the process of evaluating the ear, she removes a small amount of wax with a single pass of the curette. The patient is diagnosed with otitis media and then placed on antibiotics for the middle ear infection.

In this scenario, you should report an E/M instead of 69210. On the claim:

- report 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 moderate medical decision-making) for the E/M.

- link 382.9 (Otitis media) to 99283 to represent the patient's earwax.