Otolaryngology Coding Alert

Question: The provider performs an in-office removal of a foreign body (FB) of the earlobe through an incision. Is there a CPT^® code to report for this or would it qualify as an evaluation and management (E/M) visit?

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Answer: You should never bundle an invasive surgical procedure performed in an office setting into an E/M code. In this case, the fact that the physician needed to incise the earlobe in order to remove the FB means that you’ll be looking for the appropriate surgical CPT^® code to report. The only reason you should report an E/M code in addition to the surgery is if the physician performs a significant, separately identifiable service in addition to the FB removal (FBR).

In this example, since you’ve got documentation that supports a an FBR of the earlobe, the coding is relatively simple. You’ll report code 10120 (Incision and removal of foreign body, subcutaneous tissues; simple). Since this code has a bilateral surgery indicator of “0,” you should not append a modifier to indicate laterality.

In some cases, the provider may have to incise the earlobe before determining whether it’s an FB, or some sort of abscess/infection that’s causing the patient’s symptoms. If it turns out that an abscess drainage is the remedy, as opposed to FBR, you should make sure not to use a code from the same Surgery subsection “Surgical Procedures on the Skin, Subcutaneous and Accessory Structures.”

Instead, for a simple abscess drainage of the earlobe, you’d opt for a code in the Surgery subsection “Incision Procedures on the External Ear.” Here, you’d report code 69000 (Drainage external ear, abscess or hematoma; simple). However, keep in mind that you will be appending an RT (Right Side) or LT (Left Side) modifier to indicate laterality due to the bilateral surgery indicator of “1” for code 69000.