Internal Medicine Coding Alert

Think: 'Separate E/M is possible' when service involves internist

Patients who report to the internist for removal of impacted cerumen might require a separately reportable E/M service in addition to the procedure.

When? The reason for the office visit would need to be separate from the cerumen removal, says Steve Verno, NREMTP, CMBSI, director of reimbursement at EMS in Hollywood, Fla.

Check out this explanation from Blue Cross and Blue Shield: "An evaluation and management (E/M) code may be eligible for reimbursement in addition to code 69210" if:

• the patient's condition required a significant, separately identifiable E/M service,

• the documentation meets requirements for use of the E/M code, and

• you attach modifier 25 to the E/M code.

Example: An established patient reports to the internist for a checkup of her type II diabetes mellitus. During that evaluation, the patient complains of decreased hearing in her right ear.

After providing level-two E/M service for the patient's diabetes, the internist examines the patient's ears and finds impacted cerumen, which he removes using instrumentation. This type of scenario will allow you to report 69210 (Removal of impacted cerumen [separate procedure], one or both ears) and an E/M.

Definition: According to article A44326, "Removal of Impacted Cerumen and Evaluation and Management Services" from-the Medicare Local Coverage Determination (LCD) for Alabama, Georgia and Mississippi: "If a separate, identifiable evaluation and management service is provided during the same visit, then Medicare may cover an evaluation service if modifier 25 is added to the evaluation and management CPT code, indicating that the evaluation and management service was unrelated to the cerumen removal procedure."

So on the claim for the example scenario, you would report the following:

• 69210 for the cerumen removal

• 380.4 (Impacted cerumen) linked to 69210 to represent the cerumen

• 99212 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making) for the E/M

• 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) linked to 99212 to represent the reason for the E/M

• modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) linked to 99212 to show that the E/M and cerumen removal were separate services for separate issues.