Otolaryngology Coding Alert

Here’s who CPT^® designed the new 69209 code for.

A patient reports to the otolaryngologist with cerumen (earwax). The provider removes the earwax and sends the patient home. Coding for this service is simple, right?

Not so fast: There are a trio of coding possibilities when your provider performs cerumen extraction. The code you choose will depend on the specifics of the encounter, which will vary by claim.

Don’t let incorrect earwax removal coding prevent you from collecting for this common, yet often miscoded, procedure. Read on for expert advice on what to do when the next cerumen removal claim hits your desk.

Instrumentation + Provider + Impacted Cerumen = 69210

Coders might be tempted to slap 69210 (Removal impacted cerumen requiring instrumentation, unilateral) on every claim that includes the words “cerumen” or “earwax.” This would be hasty practice, however.

Why? The encounter must meet certain parameters in order to report 69210, confirms Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Neb.

According to CPT^® Changes 2016 — An Insider’s View, “Code 69210 only captures the direct method of earwax removal utilizing curettes, hooks, forceps and suction.” When the provider removes impacted cerumen from a patient’s ear using one of the above methods, 69210 is a likely candidate for the service. Payers might also accept 69210 if the provider uses magnification to spot and remove the cerumen, says Swanson.

Best bet: If the encounter notes indicate that the provider removed impacted cerumen using a method not listed above, check with the payer, which might accept 69210 for other methods of earwax extraction — but it might also follow the law laid down in CPT^® Changes 2016 — An Insider’s View.

Find Impacted Cerumen Evidence in Notes

To report 69210, not only does the provider need to use specific types of instrumentation — she must also remove impacted cerumen from the patient’s ear, says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa.

Check out this definition of impacted cerumen from BlueCross BlueShield of North Carolina: “To be considered clinically impacted cerumen, the physical findings must be consistent with one or more of the following”:

• “Visual considerations. Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.” 
• “Qualitative considerations. Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.” 
• “Inflammatory considerations. Associated with foul odor, infection, or dermatitis.” 
• “Quantitative considerations. Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentation requiring advanced practitioner skills. (physician or nonphysician practitioner, such as nurse practitioner, physician assistant, clinical nurse specialist).”

If you see evidence of instrument use by a physician or a nurse practitioner/physician assistant and clinically impacted cerumen on the same earwax removal claim, 69210 could be the choice.

Example: A patient reports to the otolaryngologist complaining of left ear pain. He says the pain started a “few days ago” and has gotten progressively worse. At first it was just itching, but now the patient has visible, foul-smelling earwax just inside his eardrum. Using magnification and right-angle hooks, the otolaryngologist removes the earwax and sends the patient home.

On this claim, you should report 69210 for the cerumen removal with H61.22 (Impacted cerumen, left ear) appended to represent the patient’s diagnosis.

Irrigation Steers You to 69209

When your provider removes impacted cerumen, and there isn’t evidence to support a 69210 service, you might be able to choose 69209 instead.

Again, from CPT^® Changes 2016: An Insider’s View: “Another less invasive method uses a continuous low pressure flow of liquid (e.g., saline water) to gently loosen impacted cerumen and flush it out … Code 69209 enables the irrigation or lavage method of impacted cerumen removal to be separately reported.”

Example: A nurse removes impacted cerumen from an established patient’s right ear. Encounter notes indicate that the nurse used saline solution to irrigate the ear canal, which flushed the cerumen out. On this claim, you’d likely report 69209 with H61.21 (Impacted cerumen, right ear) appended to represent the patient’s condition.

Know Who Can Code 69209

Remember, the 69209 code does not have provider work relative value units (RVUs). This is because clinical staff, not the provider, can perform cerumen removal with lavage/irrigation. This is also why the reimbursement for the 69209 is significantly less than it is for 69210.

You’ll need to check your state’s scope of practice to determine which types of clinical staff, if any, can perform 69209 in an office setting.

Takeaway: “As long as it is within the scope of practice in your state for an MA [medical assistant], RN[registered nurse], LPN [licensed practical nurse], etc., to perform an ear lavage, then it is OK to bill [69209] under the physician, given that the physician ordered the services and is on site” during the service, Falbo explains.

E/M Paves Way to Pay for Non-Impacted Cerumen

There are still instances where you’ll choose the appropriate evaluation and management (E/M) code when a provider removes cerumen, says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president of Healthcare Resource Management Inc. in Spring Lake, N.J.

“Some providers do not bill for 69209 and include it in the medical decision making [MDM] for the E/M procedure,” she explains. Other providers always bill for 69209 if the encounter notes prove that the provider removed impacted cerumen; and when the cerumen’s not impacted, they choose an E/M.

Per CPT^®, “For cerumen removal that is not impacted, see E/M service code.” According to Falbo, this means that you’ll choose the appropriate E/M code depending on the specifics of the encounter; new or established office patient (99201-99215); subsequent hospital care (99231-99233); etc.