Internal Medicine Coding Alert

Reserve 69210 for this impacted cerumen removal scenario

Coding experts who advocate applying 69210 only under strict circumstances now have a heavy hitter in their corner backing this interpretation.

The ongoing controversy over staff and procedure requirements necessary to report 69210 ended this July when AMA's CPT Assistant finally set the 69210 record straight.

Master 69210 With 3 Scenarios

See if you need to revise your cerumen coding policy--and to educate your staff on how to code ear-wax-related encounters--with this quick AMA-approved quiz:

Question: For which of the following scenarios should you report 69210 (Removal impacted cerumen [separate procedure], one or both ears)?

1. A nurse removes earwax via irrigation or lavage.

2. A primary-care physician removes earwax via irrigation or lavage.

3. A patient presents to the office for earwax removal as the chief complaint.
Documentation describes the wax as impacted cerumen because it completely covers the eardrum and causes the patient hearing loss. A primary-care physician removes the impacted cerumen with magnification provided by an otoscope and instruments such as wax curettes, forceps and suction.

Answer: Only scenario 3 qualifies for 69210, according to CPT Assistant July 2005. You should report 69210 for removal of only impacted cerumen (380.4, Impacted cerumen).

The new clinical guidelines put a damper on internal medicine practices whose insurers had more lenient medical-necessity guidelines. "Arkansas Medicare's carrier doesn't require an impacted cerumen diagnosis with 69210," says Linda Whited, CPC, coding specialist in Cooper Clinic PA's coding and education department in Fort Smith, Ark. For instance, the insurer accepts a diagnosis of hearing loss.

To help staff determine whether a case involves impacted cerumen, use the following definition, offered by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). "Code 69210 does not mean 'simple' impaction such as one that might be addressed through irrigation," says Linda J. Taliaferro, MHCM, director of regulatory and socioeconomic affairs at AAO-HNS in Alexandria, Va. Internists should consider cerumen impacted if any one or more of the following conditions are present:

• Visual: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle-ear condition.

• Qualitative: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching and/or hearing loss.

• Inflammatory: Associated with foul odor, infection, or dermatitis.

• Quantitative: Obstructive, copious cerumen that requires a physician's skill to remove with magnification and multiple instrumentations.

Capture Earwax-Removal Work in 99201-99215

If a nurse or internist removes earwax (as in scenarios 1 and 2), you should instead include the work in the appropriate-level E/M code, such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...). This new instruction shocks Whited. Nurses have been assigning 69210 for irrigation, she says.

"CPT 69210's clarification will have a big impact on physicians and coders," says Linda Weiss, billing and coding specialist at Seattle Primary Physicians. Hopefully, the AMA will eventually create an "ear irrigation" code to identify the procedure's work component as separate from the E/M service, she adds.

Use 69210 for Internist-Provided Instrumentation

For an encounter to qualify for 69210, a physician must use instrumentation to remove impacted cerumen. The internist must use, at minimum, an otoscope and instruments, such as wax curettes. The AMA adopted this new policy from many Medicare carriers' guidelines.

"Medicare carriers have always had pretty strict interpretations regarding the payment of 69210," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo. The AMA's new guidance more closely aligns CPT with carriers' policies.

New rule: You should report 69210 when the encounter meets these criteria:

1. the patient has cerumen impaction

2. the removal requires physician work using at least an otoscope and instrumentation, rather than simple lavage.

In the above examples, only scenario 3 meets the two requirements and therefore qualifies for 69210.

Benefit: You'll no longer have to guess how you should interpret 69210. "Finally, we have definite guidelines" that should make appropriately assigning the code more consistent, Weiss says.

Educate Staff on CPT's Earwax-Removal Coding

How much the new guidelines will impact your practice depends on your current 69210 coding policy. "Even when reporting claims to private payers, we follow Medicare's coding guidelines," says Mary L. Bonacci, MBA, CPC, at Johns Hopkins University in Baltimore.

If your office interprets 69210 more loosely, you'll have to redefine your code use. Coders will have to educate internists and staff on how to report cerumen-related scenarios, Whited says. Once practices are on the right track, "CPT's new directive will cut down on 69210's coding frequency," she says.

Remember: When you assign 69210, you should have a separate entry from the physician to support the procedure. "Accompanying documentation should indicate the time, effort, and equipment required to provide the service," states CPT Assistant.