Otolaryngology Coding Alert

Reporting 69210 when your otolaryngologist doesn't use instrumentation to remove cerumen could cost you big bucks in repayments for each violation. But, if you follow three simple guidelines, you could avoid any penalties.

Otolaryngology practices use several methods, including irrigation, solvents and manual disimpaction, to remove cerumen. Ancillary staff may use some of these methods, which means that many practices are unsure about what cerumen removal service qualifies for 69210 (Removal impacted cerumen [separate procedure], one or both ears) and who can perform the code.

Only one method, manual disimpaction, qualifies for 69210. Manual disimpaction involves certain risks, and 69210 requires the otolaryngologist to perform the procedure, says Cindy M. Austin, facility manager at Dothan ENT, Allergy and Asthma PC, in Dothan, Ala.

If  your ENT wants to report 69210, he or she must remove an impaction. Code 69210's descriptor specifies impacted cerumen, not simply cerumen, Austin says. "Therefore, the otolaryngologist has to work diligently to remove an impaction." If the physician can simply flush the ear out to eliminate the patient's symptoms, such as fullness of ear, an impaction really never existed, she says.

In fact, otolaryngologists petitioned the AMA to create 69210 to identify the increased surgical work an ENT employs to remove impaction, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. "The idea was that if a primary-care physician could not clean a patient's ear out using irrigation, he would refer the impacted-cerumen patient to an ENT to perform the more complex, surgical procedure."

If physicians continue to use 69210 for nonsurgical work, Cobuzzi worries that CMS will continue to decrease the relative value units (RVUs) for the code. CMS bases work RVUs on the average amount of work required to do the task. Therefore, otolaryngologists who use 69210 for washing cerumen out may dilute the meaning of the code, she says.

2. Watch for Instrument Use

One way to tell if your ENT removed an impaction is to look for instrumentation. Only a physician using instrumentation qualifies for 69210, says Sherry Moss, a consultant with Spectrum Business Systems Inc. in Fort Lauderdale, Fla. "Many doctors don't want to hear what 69210 really entails," she adds.

In the Coders' Desk Reference (CDR) eighth edition, the description of CPT's 69210 states, "under direct visualization, the physician removes impacted cerumen (ear wax) using suction, a cerumen spoon or delicate forceps," Moss says. That means the ENT really has to "dig out the ear wax" to bill 69210, she says.

Correct 69210 coding example: The otolaryngologist may view the patient's ear using binocular magnification and grasp the cerumen plug with forceps. In this case, Florida Medicare's local medical review policy (LMRP) indicates that you should bill 69210.

Ear canal irrigation and chemical solvents, however, do not qualify for 69210, according to numerous Medicare LMRPs, as well as the CDR.

Softening-agent scenario: A nurse uses a chemical agent to soften a 65-year-old Medicare established patient's ear wax. Because the nurse performs the service and the removal does not require instrumentation, you should not report 69210 in this case, Moss says. You should instead report the appropriate E/M service, Florida's Medicare LMRP states.

"If the doctor does not see the patient, report a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient ... typically 5 minutes are spent performing or supervising these services) for the service," Moss says. But if the otolaryngologist sees the patient and orders the nurse-performed cerumen removal, you should report the appropriate level of E/M service (99212-99215).

Note: Rates based on the 2003 National Physician Fee Schedule Relative Value File.