Otolaryngology Coding Alert

Question: When we bill an impacted cerumen removal (69210) with an office visit (99201-99215), the insurance company bundles it. We have tried attaching modifier 25 to the E/M code. Should we attach a different modifier to 69210?

Alabama Subscriber

Answer: First of all, look back at your physician notes. You need to know how he's performing the removal of the impacted cerumen. If the ENT is only doing an ear wash and it does not require a) substantial physician skill and b) the use of instruments such as currettes, etc., you cannot bill 69210 (Removal impacted cerumen [separate procedure], 1 or both ears). If the ENT's notes do not meet the above definition, you should consider the service included in the office E/M service (99201-99215, Office or other outpatient visit ...).

The only time you'll receive separate payment for both an E/M visit in addition to the removal of impacted cerumen is if the E/M service is for something totally unrelated from the impacted cerumen. This means the ENTs documentation for the E/M service is significantly and separately identifiable.  

Don't miss: Although CMS says you don't need a different diagnosis for the E/M service and only require a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), that is not true in the case when the physician is removing impacted cerumen. This procedure is held to a higher standard. You need a totally different diagnosis for the E/M (such as nasal congestion, 478.19, Nasal obstruction). Then you would apply 380.4 (Impacted cerumen) to 69210. If you don't receive payment for 69210 with the separate diagnosis, then you have to appeal. Warning: You still have to make sure the removal of the wax meets the definition of 69210 and that you have a procedure note to support the removal of the impacted cerumen.

ICD-10: When your diagnosis coding shifts to ICD-10, 478.19 will become R09.81 (Nasal congestion), and 380.4 will become H61.2- (Impacted cerumen ...), based on whether the condition occurs in the right ear, left ear, both ears, or unspecified.