Otolaryngology Coding Alert

Question: I have a new patient present with impacted cerumen removal. Since this patient is brand new to the practice, may the provider bill for the evaluation and management (E/M) service in addition to the cerumen removal?

Montana Subscriber

Answer: As is discussed in the article “Bank on This Definitive Coder’s Guide to Cerumen Removal,” there are four criteria that you must meet according the American Academy of Otolaryngology — Head and Neck Surgery (AAO-HNS):

• “The initial reason for the patient's visit was separate from the cerumen removal;
• Otoscopic examination of the tympanic membrane is not possible due to the impaction;
• Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner and is personally performed by him or her; and
• The procedure requires a significant amount of time and effort, and all of the above criteria are clearly documented in the patient's medical record.”

Without the chart notes available to outline the complete circumstances behind the patient’s visit, there is no definitive answer to this question. However, it’s important to make a point of the first bullet point. Based on this first piece of criteria, the reporting of a separate E/M service hinges on the underlying reason for the visit. If the underlying reason for the visit is to treat the cerumen removal, then you should only consider codes 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) or 69210 (Removal impacted cerumen requiring instrumentation, unilateral), depending on the method of removal.

Keep in mind that there is no E/M mandate that requires that you report an E/M code for a new patient visit. So, as long as the symptoms and/or chief complaint are directly tied to the cerumen removal procedure, there’s no justification to include a new patient E/M code alongside the cerumen removal procedure code.

Look out for a future issue of Otolaryngology Coding Alert where we will further discuss when and how to address new patient E/M visits involving minor procedures.