Internal Medicine Coding Alert

Question: An established patient complaining of pain in her inner left ear reports to the internist for treatment. The internist performs an E/M service and reaches a diagnosis of infected otitis externa. Then, he soaks a wick in antibiotics and inserts it into the patient's ear canal. How should we report the ear wick insertion?

Massachusetts Subscriber

Answer: There is no CPT code for ear wick insertion. Therefore, if the physician performs an insertion with no other procedure(s), you should roll the insertion work into the overall E/M code.

Suppose the E/M documentation, including wick insertion, amounts to a level-two service. On the claim, you would report 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; straightforward medical decision-making) for the service.

Also, append ICD-9 code 380.10 (Infective otitis externa, unspecified) to the E/M code to prove medical necessity for the visit.

-- Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of government program services for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.