Internal Medicine Coding Alert

Question: The internist documented that a patient has "wax bilaterally" and that the nurse removed the wax by "flushing ears bilaterally." Can we report 69210 in addition to an E/M?


North Carolina Subscriber

Answer: You should use 69210 (Removal impacted cerumen [separate procedure], one or both ears) only when the internist removes "impacted" cerumen, not simple earwax blockage.

For instance, if your physician or nonphysician practitioner used an operating microscope or forceps to remove impacted cerumen, you should assign 69210. Also, you should link 380.4 (Impacted cerumen) to 69210 to show medical necessity. Note: Payers vary on their guidelines regarding acceptable methods for removing impacted cerumen, so check with your carrier for specific requirements.

Remember that if the physician or a nurse was able to easily remove the wax, then you shouldn't report 69210. In that case, your best bet would be an E/M code (99201-99215). If you're able to use 69210 and want to bill an E/M as well, be sure you attach 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 code.