Internal Medicine Coding Alert

Question: An established Medicare patient reported to the internist with "painful" wax buildup in her left ear. One of our nonphysician practitioners (NPPs) removed the wax using lavage, some solvents, and, ultimately, curettage. Can we report 69210 for this encounter? Or is 69210 for physicians only?

Indiana Subscriber

Answer: There are two questions here, so we'll address them one at a time:

Can we report 69210? With Medicare, you should be able to report 69210 (Removal impacted cerumen [separate procedure], one or both ears) for this visit based on your description. Keep in mind, however, that for Medicare you would report this service under the NPP's national provider identifier (NPI) number.

If you cannot prove the cerumen is impacted, you may want to think twice about reporting 69210. Payers may vary slightly as to what they consider impacted cerumen (380.4) for coding purposes, but the condition is typically marked by earwax blocking a portion of the external auditory canal or the tympanic membrane. This wax is often hard, dry, and painful.

During a 69210 encounter, the provider typically removes the cerumen using one of these instruments: suction, probes forceps, right angle hooks, or wax curettes.

In addition to 69210, the NPP likely provided an E/M service to this patient. Go back and check the encounter notes for E/M evidence; if you do file an E/M along with 69210, be sure to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M to show that it was a separate service.

Is 69210 for physicians only? It depends on the carrier. As long as it is within the NPP's scope of practice, she has the proper state licensure, and she uses instrumentation to remove impacted cerumen, most insurers will pay for 69210 that an NPP performs.

Best practice: If you are unsure about a payer, check your contract or contact a rep, then file the claim.