EM Coding Alert

Separate the E/M from 69210 with modifier 25 to get deserved dollars.

When your provider sees a patient in the office and then performs cerumen removal, determining whether or not you can separately report an E/M code is not always straightforward. But erring on the side of caution and skipping the E/M code every time can cost your practice big time. 

Keep reading to unravel these issues and ensure you aren’t missing billable services.

Check the Severity to Know the Need for E/M

When your physician removes cerumen that isn’t impacted or doesn’t require instrumentation, where irrigation will remove the cerumen, you will report only an E/M code from the 99201-99215 (Office or other outpatient visit …) range. 

“Payers typically will not cover simple, non-impacted earwax removal,” says Barbara Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CPCO, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “This work is included in the E/M service and should be reported with an E/M code.  Further, if earwax is removed by irrigation or lavage only, CPT® 69210 (Removal impacted cerumen requiring instrumentation, unilateral) should NOT be reported, as this is considered part of an E/M as well.”

There are times, however, when you can — and should — separately report an E/M service and the cerumen removal with 69210.

“The key is how the 69210 was documented,” explains Dorothy D. Steed, CPC-H, CHCC, CPUM, CPUR, CPHM, ACS-OP, CCS-P, RCC, CPMA, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, AHIMA approved ICD-10 trainer, an independent healthcare consultant and educator in Atlanta, Ga. ”If an instrument was used, such as a curette, this must be indicated by the provider, and payers are more inclined to pay it separately with modifier 25 on the E/M code.  If done by a washing, or similar method without using an instrument, it is bundled into the E/M, and not separately payable.”

Example: A patient presents with a sore throat and while in the doctor’s office, she complains of an itchy ear and difficulty hearing. Your physician examines the patient and determines that the patient has impacted cerumen.  He removes the cerumen with otoscope and a curette, digging out the impacted cerumen.

Code it: You would code the E/M visit using a new or established patient office visit code (99201-99215) depending upon the levels of history, exam, and medical decision making your provider documents. Attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to indicate that the office service is separately identifiable and separately payable. Report the cerumen removal procedure with 69210.

Tip: “I suspect a common problem is failure to append modifier 25 to the E/M code,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Kan. “CCI edits do bundle an E/M into 69210 unless an appropriate modifier is used. The other point to remember is that 69210, like all procedures, includes a certain amount of evaluation and management in preparation for doing the procedure. Thus, unless the documentation supports, and the claim reflects that the E/M done in conjunction with 69210 was significant and separately identifiable from 69210, the payer will deny the E/M.” Conversely, the other problem is removing the impaction with only water and billing separately for it under the 69210. This is not appropriate billing/coding. The physicians should be made aware of when the impaction removal is billed separately and when it is not.

Look for Two Diagnoses to Ensure Payment

You’ll find that most payers consider cerumen removal a minor procedure but they require two separate diagnoses in order to pay for the E/M service and the cerumen removal procedure, which isn’t typical for other minor procedures. Without the two diagnoses, denial is likely.

The E/M service may originate with ear pain or trouble hearing as one diagnosis, as well as possibly 380.4 (Impacted cerumen). The ear pain or trouble hearing most likely brought your patient into the office. 

So on your claim, you would bill the E/M service with modifier 25 and the presenting problem diagnosis — ear pain (388.70, Otalgia unspecified) or trouble hearing (389.9, Unspecified hearing loss) — and the 69210 with 380.4 for the impacted cerumen the provider found and treated.