Otolaryngology Coding Alert

See how cerumen removal coding changes when audiologists get involved.

It’s easy to get caught using tunnel vision when it comes to cerumen removal coding for a Medicare Part B patient. For the most part, coders are conditioned to take a few algorithmic steps in determining whether the service qualifies as an impacted cerumen removal visit.

However, depending on the circumstances surrounding the patient encounter, there may be a few more important factors to consider. For instance, if the patient has audiology testing on the same day as the cerumen removal, you’ve got to know how the coding mechanics change fundamentally.

Zone in on some of the lesser-discussed rules surrounding cerumen removal and audiology visits. Plus, check out a few extra tips to clear up confusion on foreign body removal (FBR) coding.

Find Out 69209 Rules on Physician Supervision

The first point you’ll want to address regarding the removal of impacted or non-impacted cerumen is what kind of provider is eligible to perform a given service. For the removal of non-impacted cerumen that’s billed as an E/M visit, the service may be performed by trained office personnel without the supervision of the physician or another qualified health care professional. Furthermore, code 69210 (Removal impacted cerumen requiring instrumentation, unilateral) should be performed by a physician or other qualified health care professional.

However, when it comes to the reporting of 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) you’ll want to refer to this CPT^® Assistant (January 2016; Volume 26: Issue 1) guideline:

• “May be performed by trained office personnel under the supervision of the physician or other qualified health care professional.”

As you can see, with the added degree of difficulty removing the impacted cerumen using irrigation or lavage, the physician should be present in the office suite to supervise the procedure. However, you’ll want to know exactly what CPT^® Assistant means when it refers to “other qualified health care professional.”

For all intents and purposes, you can consider a “qualified health care professional” to fall under the scope of any advanced practice provider (APP), which includes physician assistants (PAs) and nurse practitioners (NPs).

Use G0268 for Cerumen Removal in the Right Setting

If your otolaryngology practice has an audiology department, you should be aware of instances when it’s appropriate to report HCPCS code G0268 (Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing) in place of 69209 or 69210. Consider a scenario where a patient presents to the otolaryngologist for hearing impairment in which the physician removes impacted cerumen through the use of a wax curette and suction. Following the cerumen removal, the patient presents to the audiology unit for impedance testing and a comprehensive audiometry threshold evaluation and speech recognition examination.

For the audiology testing, you’ll report under the Audiologist’s National Provider Identification (NPI) 92567 (Tympanometry (impedance testing)) and 92557 (Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)), respectively. However, you will not report 69210 for the cerumen removal. Instead, you’ll submit the cerumen removal under code G0268 under the physician or other qualified healthcare provider’s national provider identification (NPI).

Coder’s note: If you find yourself in a scenario where the use of G0268 applies, you’ll want to know that it doesn’t matter if a separate physician, audiologist, or advanced practice provider (APP), or even a technician performs the audiologic function testing. G0268 still applies when the provider performs both services, or the cerumen removal exclusively.

Abide by These Foreign Body, Cerumen Removal Rules

First, you should clear up when it’s appropriate to report 69200 (Removal foreign body from external auditory canal; without general anesthesia) with 69209 or 69210. In any instance where the physician removes a foreign body from the same ear that they perform an impacted cerumen removal, you should bundle the cerumen removal into the foreign body removal. National Correct Coding Initiative (NCCI, or CCI) Procedure-to-Procedure (PTP) edits bundle 69209 and 69210 into 69200 under a modifier indicator of “1.” The only reason you should override this modifier is by adding a laterality modifier to indicate the cerumen removal was performed on the contralateral ear.

There are other instances in which a coder may struggle in discerning between whether a procedure qualifies as 69200, 69209/69210, or a separate code. For example, consider a scenario where the provider documents the removal of debris and/or pus from the ear canal due to a fungal infection via a suction technique.

You may feel initially inclined to consider reporting 69200 in this situation, but unless the physician clearly documents a true foreign body within the ear canal, 69200 is inappropriate. A foreign body, as defined by Dorland’s Illustrated Medical Dictionary, is “a mass or particle of material that is not normal to the place where it is found.” Given that the patient has a documented fungal infection within the ear, the documented symptoms of the fungal infection (debris, pus) are clearly not an abnormal finding.

You’ll also reserve codes 69209 and 69210 for impacted cerumen diagnoses exclusively. In fact, in the case of debridement and/or removal of debris through various methods, you should consider the service as an included component of the underlying E/M visit. “These sorts of services are typically included in the E/M visit,” says Kimberly Quinlan, CPC, senior medical records coder for the University of Rochester Medical Center’s Department of Otolaryngology in Rochester, New York. “However, you may consider billing the visit to a higher level if the debridement proves difficult and the physician winds up spending quite a bit of extra time with the patient.”

“Also, keep in mind that although the definition of 69210 has been changed to be a unilateral code, Medicare Part B still treats 69210 as a unilateral or bilateral code,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “This means that Medicare Part B will not accept 69210 with modifier 50 (Bilateral Procedure) when impacted cerumen is removed from both ears,” explains Cobuzzi.