Internal Medicine Coding Alert

69210 or E/M inclusion depends on service and provider.

A patient visits your office, complaining of ear pain. The physician orders an ear irrigation. Can you legitimately report 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) for the care? Ask yourself three questions to keep your irrigation claims in the clear.

Was It Simply Irrigation?

Sometimes a provider can clear the patient's ear with basic irrigation, but sometimes he needs to use more extensive measures. Before choosing 69210, verify the level of service provided.

"You cannot bill 69210 if the provider only does irrigation," says Randa Cain, CPC, coding and charge capture supervisor with Martha Jefferson Medical Enterprises/Central Business Office in Charlottesville, Va. "There has to be use of some type of instrumentation to 'dig out' the impaction." If the internist does just an irrigation, it's included in the E/M service.

Before submitting 69210, the provider's documentation should clearly show that he removed impacted cerumen. Procedure notes should include the following details:

• That the physician performed the procedure
• That the ear had impacted cerumen
• Why the physician removed the cerumen
• How the physician removed the cerumen (what tools he used, such as a scoop or curette)
• The outcome (canal cleared, could visualize eardrum, etc.).

"If you need to appeal the claim, the note you send should support the documentation outlined above," says Janet Farrell, CPC, CMBS, with Practice Resources, LLC, in Syracuse, N.Y.

Tip: Some payers want you to append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M office visit code when you submit 69210 at the same encounter. "Remember the E/M should only be billed when the work involved is separately identifiable and above and beyond the work involved in removing the impacted cerumen," notes Farrell. The documentation of the E/M service should, ideally, be separate from that of 69210, and it should support the level of E/M service reported. Per CPT®, the E/M service may be prompted by the symptom or condition (e.g. ear pain) for which the impacted cerumen removal was provided. As such, different diagnoses are not required for the E/M and 69210.

Who Performed the Service?

Before considering 69210, also verify who treated the patient.

"The internist must be doing the service to report 69210," Farrell says. Translation: Steer clear of 69210 if the nurse cleans the ear.

Scenario: Imagine that a patient with ear pain sees the doctor, who recommends irrigation. The nurse performs the procedure after the physician sees the patient. The physician sees the patient again, to ensure that the ear canal is clean. Even though the physician saw the patient twice during the same office visit, he didn't perform the procedure. That means you'll include the cleaning as part the E/M service, not a separate procedure. Code 69210 is intended to represent physician work.

What's the Best Diagnosis?

Many payer policies state that 380.4 (Impacted cerumen) is the only appropriate diagnosis to report in conjunction with 69210. You might report additional diagnoses, however, to support an associated E/M code or to document associated signs and symptoms. Options might include ear pain (388.7x, Otalgia), otitis media (381-382), or another illness (such as 465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site).

Example: A patient complains of ear pain. Impacted cerumen blocks the eardrum, preventing the physician from examining the ear. The physician uses an otoscope and curette to remove the impaction. She then examines the ear and diagnoses the patient with acute purulent otitis media.

In this case, you have two diagnoses -- 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum) and 380.4. You should use the otitis media diagnosis (382.00) with the E/M service with modifier 25 appended to the E/M code, and the removal of impacted cerumen (380.4) with the procedure, 69210.