Internal Medicine Coding Alert

Look to CCI when coding for multiple procedures.

Scenario 1: Simple Removal by Irrigation

What to report: In this case scenario, you will have to report only the appropriate established patient E/M code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) for the visit.

If your clinician removes impacted cerumen through lavage or irrigation, you will report it with the CPT^® code, 69209 (Removal impacted cerumen using irrigation/lavage, unilateral). “In order to report 69209, it is essential that the cerumen that your clinician removed from the ear is impacted,” says Melody Lidmila, CPC, CEC, Coding specialist at the University of Colorado Health in Loveland.

“The description of the code will guide the provider on what condition the patient has and what needs to be performed and thus documented in order to bill one of these codes,” says Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, senior principal of ACE Med, a medical auditing, coding and education organization in Pittsburgh, Pa. “If cerumen in NOT impacted, the instructional notes in CPT^® say to use an E/M.” The inclusion of the term “impacted cerumen” in the code descriptor to 69209 and a parenthetical note after the code reinforces this point.

So, when you cannot report 69209 for the removal of cerumen that is not impacted, if your clinician performs this procedure, you will just have to include the work in the E/M service code that you are reporting for the visit. “Bill the E/M only if cerumen is not impacted,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa.

Scenario 2: Bilateral Removal

What to report: In this case scenario, you will have to report 69210 (Removal impacted cerumen requiring instrumentation, unilateral) for the removal of the impacted cerumen in the right ear using instrumentation. “When reporting bilateral removal procedures using different methods, you will have to report 69210 and 69209-59,” Lidmila says. You report 69209 for the removal of the impacted cerumen from the left ear using irrigation. You will need to append modifier 59 (Distinct procedural service) to 69209.

As your clinician performed impacted cerumen removal from both the ears using two different methods (instrumentation and irrigation), you will report both the codes, 69210 and 69209, for the same patient on the same calendar date of service. “The documentation would have to clearly illustrate the two separate procedures on separate ears,” Hauptman says. Since the two codes are bundled by Correct Coding Initiative (CCI) edits and since 69209 is the Column 2 code in the edit, you will have to append the modifier 59 to 69209 to enable reimbursement for both the codes.

Scenario 3: Cerumen Removal/Unrelated E/M

What to report: In this case scenario, you will have to report 69209 for the removal of the impacted cerumen and report the appropriate established patient E/M code with the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to it.

Although you will not always report an E/M code either with 69209 or with 69210, you will have to watch out for opportunities when you can report an E/M code for the encounter. You will only be able to report an E/M code if your clinician performed an evaluation of the patient that was distinct and separately identifiable from the cerumen removal procedure performed.

Since in this case scenario, your clinician evaluated the patient for his blood sugar levels and also performed the cerumen removal through irrigation, you can report the E/M code separately (with modifier 25 appended) with 69209. Failure to append modifier 25 to the E/M code may result in denial of the E/M service, since CCI edits otherwise bundle E/M codes into 69209.

Scenario 4: Injection and Cerumen Removal

What to report: In this case scenario, you will have to report the cerumen removal procedure using instrumentation with 69210. You report the administration of the B-12 injection with 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) with the modifier 59 appended to it. “If the services are performed and documented appropriately, they can be billed on the same claim,” Hauptman reasserts.

According to CCI edits, the injection code 96372 is bundled into the code for cerumen removal (69210). However, the modifier indicator for this code bundle is ‘1,’ which means you can separately report the codes by using a suitable modifier. Since the injection code is the column 2 code in the edit bundle with 69210, you append the modifier to 96372.

Don’t forget to also report a code for the B-12 itself. In this case, it is likely J3420 (Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg).

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