EM Coding Alert

Question: Our general practitioner (GP) recently saw a patient with an infection of the left inner ear. Notes indicate that he inserted an antibiotic-soaked ear wick to treat the infection. Is there a code for ear wick insertion?

New York Subscriber

Answer: You do not have any specific code for the ear wick insertion that your clinician performed for the patient.

Report the appropriate-level E/M code for the encounter.

Benefit: You’ll roll the ear wick insertion work into the rest of the E/M service before deciding on a code.

Let’s suppose documentation reflects a level-three established patient E/M service. You will report 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) for the E/M service with an appropriate ICD-10code, such as H83.02 (Labyrinthitis, left ear) appended to the E/M code to inform the payer about the medical necessity of performing the E/M service.