Question: I have a new patient present with impacted cerumen removal. Since this patient is brand new to the practice, may the provider bill for the E/M service in addition to the cerumen removal? Illinois Subscriber Answer: According the American Academy of Otolaryngology — Head and Neck Surgery (AAO-HNS), there are four criteria that you must meet to bill for both services: Without the chart notes available to outline the complete circumstances behind the patient’s visit, there is no definitive answer to this question. However, based on the first criteria, the reporting of a separate E/M service hinges on the underlying reason for the visit. If the underlying reason for the visit is to treat the cerumen removal, then you should only consider codes 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) or 69210 (Removal impacted cerumen requiring instrumentation, unilateral), depending on the method of removal. Keep in mind that there is no mandate that requires that you report an E/M code for a new patient visit. As long as the symptoms and/or chief complaint are directly tied to the cerumen removal procedure, there’s no justification to include a new patient E/M code alongside the cerumen removal procedure code.