Otolaryngology Coding Alert

Question: Is it appropriate to bill 69210 when cerumen is not considered impacted? For instance, documentation indicates, "Otologic exam reveals a mild amount of wax in her right ear, which was removed atraumatically with the cerumen loop under otomicroscopy." Does this note support billing 69210? Should I consider the procedure part of the E/M, or could I bill for it with 69210-52?

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Answer: Code 69210's descriptor specifies removal of impacted cerumen (380.4). To use that diagnosis, the otolaryngologist must state "impacted" cerumen. Most payers restrict 69210 pay to 380.4.

If the documentation does not support that definition, you should not use 69210. Removing wax that is not impacted does not warrant the reporting of 69210, according to the July 2005 CPT Assistant, published by the AMA in collaboration with the American Academy of Otolaryngology (AAO-HNS). The article defines impacted cerumen as one or more of the following: impairing "exam of clinically significant portion of the external auditory canal, tympanic membrane, or middle ear condition," possibly "extremely hard, dry and irritative - causing symptoms, such as pain, itching and hearing loss," "associated with foul odor, infection or dermatitis," or of such obstructive, copious amount that a physician's skills are necessary to remove it under magnification and with multiple instrumentation. Further, modifier 52 (Reduced service) use cannot destroy the code's base, which in this case is the removal of impacted wax.

Best practice: Report the E/M, such as 99201-99215 (Office visit for the evaluation and management of an established patient -), advise the AMA and AAO-HNS. If documentation indicates medical necessity for the "otomicroscopy," such as "needed to use binocular microscope to help clean ear out," you could also code the binocular microscopy (92504, Binocular microscopy [separate diagnostic procedure]). In these cases, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M, provided documentation supports the service as significant and separate from the binocular microscopy.