Internal Medicine Coding Alert

Question: Our internal medicine specialist recently saw a patient with infection of the left inner ear. In order to treat the infection, he inserted an ear wick that contained an antibiotic. Is there any code to report this procedure that our clinician performed?

New York Subscriber

Answer: You do not have any specific code for the ear wick insertion that your clinician performed for the patient. You will only have to report an appropriate E/M service code for the encounter. The work involved in the ear wick insertion is bundled into the E/M code that you will report for the encounter and can also be used to determine the level of E/M service that you will report.

Let us suppose if the patient documentation reflects a level-three established patient E/M service. You will report 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) for the E/M service performed. You will need to attach an appropriate ICD-10-CM code, such as H83.02 (Labyrinthitis, left ear), to the E/M code to inform the payer about the medical necessity of performing the E/M service.

Your clinician might perform the ear wick insertion while performing another procedure such as ear drainage. In such a case, the wick insertion that your clinician performed will be included in the procedural code that you will report for the ear drainage. Ear wick removal would be inclusive of the follow-up care performed during the postoperative period of the procedure. As noted, when the insertion or removal of an ear wick(s) is performed in the absence of another intervention, then it is considered a minor procedure not otherwise reported by CPT^®, and included in the E/M service.

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