Otolaryngology Coding Alert

Plus, don’t let an impacted cerumen Dx throw you for a loop.

Office visits involving the removal of a foreign body (FB) may not be especially common, but typically occur with enough frequency that it’s important to know what sort of pitfalls to avoid during the coding process. There are numerous variables to consider when coding an in-office foreign body removal (FBR), with one of the most important being the diagnostic component.

As you’ll see, if you don’t have the documentation to support the FB diagnosis, the entire coding dynamic of the visit changes.

Have a look at a few examples spanning various different scenarios to give yourself the best shot at success coding FBR procedures.

Know How To Identify FB Criteria

Example: Physician sees a child complaining of pain in her left ear during an office visit. The physician performs a non-impacted cerumen removal and subsequently removes few hair fibers lodged in the ear canal using alligator forceps.

Ultimately, it’s the diagnosis that’s going to determine how you code the entirety of this procedure. If you’re able to establish that the physician removes a true FB from the ear canal, you’ll have enough documentation to support code 69200 (Removal foreign body from external auditory canal; without general anesthesia) with modifier LT (Left Side). If you’re able to conclude that an item removed from the ear is not a FB, and the physician documents the cerumen as non-impacted, you should report the appropriate evaluation and management (E/M) code.

Dorland’s Illustrated Medical Dictionary defines a FB as “a mass or particle of material that is not normal to the place where it is found.” However, this doesn’t give you a conclusive answer as to whether you may consider the hair to be a FB. If the physician determines that the hair originated from the child’s head and was placed in the ear canal, a FB diagnosis is appropriate. If the hair growth originates from the ear canal — or if the physician cannot make a determination one way or the other — then you should err on the side of caution and code the visit with an E/M code.

If the physician concludes the hair is a FB respective to the ear canal, you’ll report diagnosis code T16.2XXA (Foreign body in left ear, initial encounter) with code 69200. If the physician’s diagnosis yields inconclusive or native to the ear canal, you’ll instead report the patient’s signs and symptoms to the respective office visit code. In this case, that would be diagnosis code H92.02 (Otalgia, left ear).

Coder’s note: “If you determine the object the surgeon removes from the ear canal is not a FB, your choice of ICD-10-CM code will depend on a few variables,” explains Ronda Tews, CPC, CHC, CCS-P, AAPC Fellow, director of billing and coding compliance at Modernizing Medicine in Boca Raton, Florida. Tews advises that asking the right set of questions will help you in your quest for the most accurate diagnosis code. For example:

Does this patient have a history of surgical procedures on or in the affected ear?

Could this be considered an ear deformity?

“If the patient has had an ear procedure done recently, then you may find an appropriate diagnosis in the H95 [Intraoperative and postprocedural complications and disorders of ear and mastoid process, not elsewhere classified] section of ICD-10-CM manual. Furthermore, a removal involving the component of a congenital ear defect means you should consider category codes Q16 [Congenital malformations of ear causing impairment of hearing] or Q17 [Other congenital malformations of ear],” relays Tews.

Forget About Technique When Coding 69200

Example: The physician performs an in-office FB removal using lavage of the right ear.

Contrary to some popular belief, the technique with which your physician removes the FB does not determine whether the service is eligible for reporting of code 69200. So long as the item removed meets the criteria for a true FB, the provider may opt to remove it using any method they so choose. In fact, you won’t find any existing authoritative guidelines that shed further light on technique for auditory canal FBRs. This example supports the use of code 69200 with modifier RT (Right Side).

Consider Access Pathway Rule With Impacted Cerumen

Example: The physician sees a child complaining of left ear pain for an in-office visit. The physician removes a layer of impacted cerumen to discover a bead from a necklace further down the ear canal, which is also removed.

If you’ve ever been presented with a similar clinical scenario involving the removal of impacted cerumen and a FB, then you probably are aware that there’s a National Correct Coding Initiative (NCCI) edit between 69200 and 69210 (Removal impacted cerumen requiring instrumentation, unilateral). The edit reveals a modifier indicator of “1,” which means you may override the edit in some instances.

However, this scenario does not warrant the use of a modifier 59 (Distinct Procedural Service) or XU (Unusual non-overlapping service…) since the removal of the impacted cerumen is a prerequisite to the removal of the FB. “Since you need to remove the cerumen in order to access the FB, the removal of the FB is the only portion of the service that warrants a CPT^® code,” explains Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center’s Department of Otolaryngology in Rochester, New York. In this example, you will report 69200 with modifier LT.