Otolaryngology Coding Alert

Question: Can I bill for 69210 with an evaluation and management (E/M) visit if the physician removes non-impacted cerumen (earwax) via lavage and proceeds to apply softening drops?

Illinois Subscriber

Answer: If a patient presents for an office visit and the provider subsequently removes non-impacted cerumen, you should not bill out for 69210 (Removal impacted cerumen requiring instrumentation, unilateral) in addition to the E/M consultation. If the cerumen is impacted, you can bill out with 69210 in addition to the E/M visit. The American Academy of Otolaryngology — Head and Neck Surgery outlines the criteria that need to be met in order for cerumen to be considered impacted:

• Cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition;
• Extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, hearing loss, etc.;
• Cerumen is associated with foul odor, infection, or dermatitis; or
• Obstructive, copious cerumen cannot be removed without magnification and multiple instrumen­tations requiring physician skills.

If none of these four criteria are met, then the cerumen removal is included in the patient’s E/M visit. This is true regardless of whether the nurse practitioner (NP) or physician removes the cerumen.

Keep in mind: If the above example did involve impacted cerumen removal, you would not use code 69210 without the use of instrumentation. Instead, you would apply code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral). However, 69209 still would not be included in the E/M visit unless the E/M visit is completely unrelated to the impacted cerumen removal. The provider or NP would need to provide sufficient documentation proving that the E/M service was significant and separately identifiable from the cerumen removal. In this case, you would need an entirely separate diagnosis for the E/M visit, with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended, in addition to 69209.