Outpatient Facility Coding Alert

Question: How to we bill an impacted cerumen removal with general check-up at our outpatient clinic? Should we append a modifier?

Texas Subscriber

Answer: Follow the physician’s note as your guide. If the physician is only doing an ear wash, you cannot bill 69210 (Removal impacted cerumen requiring instrumentation, unilateral). Ear wash neither needs specialized skill nor use of specialized instruments like curretes. In this case you need to include the service in the E/M care (99201-99215, Office or other outpatient visit ...).

You would code 69210, however, when the provider uses an instrument such as a curette, vacuum evacuation, or forceps to remove entrapped wax from a patient’s external auditory canal. The physician’s documentation should note this level of service.

Tip: Code 69210 is a unilateral procedure. If the physician removes impacted cerumen from both ears, then you must follow payer guidelines for reporting a bilateral procedure, such as appending modifier 50 (Bilateral procedure) to the code.

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 documentation for the E/M service is significantly and separately identifiable from the cerumen removal.  

Although CMS says you don’t need a different diagnosis for the E/M service and only requires 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.

Transition to ICD-10: For ICD-10 coding system, 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.