Part B Insider (Multispecialty) Coding Alert

Question: When we report 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) with an office visit, we typically append modifier 25 to the E/M service but the cerumen removal is being denied. Should we instead be putting the modifier on 69210?

Answer: It sounds like you coded correctly if your physician documented properly, but you must first check the record to ensure that you were justified in billing both services together.

Your first step is to determine how the physician removed the cerumen, and if it was indeed impacted. If the doctor merely performed an ear wash or flicked wax out of the way to visualize the ear canal, you cannot report 69210. To collect for cerumen removal, the procedure must require substantial physician skill and the use of instruments such as curettes must be employed.

The only time an E/M is payable in addition to the removal of impacted cerumen is if the office visit is performed for something totally unrelated from the impacted cerumen and the E/M service is significantly and separately identifiable to anyone reading the notes.

So, although CMS does not require separate diagnoses for the E/M service with modifier 25 appended when billed with 69210, many MACs will unfortunately only reimburse you for this service if you're reporting separate diagnoses.