Part B Insider (Multispecialty) Coding Alert

Carriers come out with strict policies on cerumen removal

If you-re billing cerumen removal code 69210 when your nurse or medical assistant (MA) simply washes out ear wax, you could find yourself in your carrier's sights.

Cerumen removal requires a physician's skill in cases where a nurse or MA risks perforating the patient's tympanic membrane (TM), according to a new local coverage determination from Empire Medicare Services. You should only bill 69210 if a physician or non-physician practitioner performed that service.

The patient should have symptomatic impacted cerumen, or the physician should be unable to evaluate or examine other signs and symptoms due to cerumen, Empire says. You can also bill G0268 for cerumen removal, if your physician removes cerumen on the same date as an employed audiologist performs audiologic function testing, Empire says.

Another carrier, First Coast Service Options, goes into more detail: Cerumen removal -is performed by the physician under binocular magnification and generally entails grasping the cerumen plug with forceps, application of suction, and/or extraction with a right-angle hook. In cases of severely impacted ears, injections of local anesthesia may be required.-

Caution: You-ve already been warned that ear-wash doesn't count as cerumen removal. The July 2005 CPT Assistant said, -Removing wax that is not impacted does not warrant the reporting of CPT code 69210.- If the wax is truly impacted, the physician should at minimum use an otoscope and instruments such as wax curettes, or an operating microscope and suction plus specific ear instruments.

Your documentation could say something like: -The patient's wax could not be adequately removed for evaluation of the complete ear canal, middle ear space, and tympanic membrane by the usual means employed by the office staff due to lack of patient cooperation. There-fore, Doctor X was needed to remove the hard wax with use of the operating microscope and micro instruments medial to the isthmus from what was found to be a micro diameter canal, in order to evaluate the patient's ear complaint of decreased hearing and ear pain,- says David Fink, an otolaryngologist in Dearborn, MI.

Note: 69210 is one of the few procedures for which Medicare requires a different diagnosis code for an evaluation and management visit on the same day with the 25 modifier, says Barbara Cobuzzi with CRN Healthcare Solutions in Tinton Falls, NJ.  Also, Medicare imposes frequency limits on cerumen removal, so you should ask your patients to sign Advance Beneficiary Notices (ABNs) in case another physician has billed 69210 for the patient recently, says Cobuzzi.