Pediatric Coding Alert

Warning: Ear wash doesn't meet 69210's instrumentation requirement

If you bill 69210 for cerumen removal and ear washes, you need to review the code's requirements -- or risk accusations of improperly using it.
 
The AMA has weighed in on what warrants 69210 (Removal impacted cerumen [separate procedure], one or both ears). Before you greenlight 69210, make sure the procedure involved these items.

1. Verify Claim Warrants ICD-9 Code 380.4

 
You should report 69210 only when documentation shows that the patient had impacted cerumen (380.4, Impacted cerumen). Code 69210 describes removal of "impacted cerumen," not removal of cerumen. CPT Assistant July 2005 states that "mere wax removal (e.g., via lavage) does not warrant 69210," says Marie West,  CCS-P, CMSCS, CCP, in Edmond, Okla.
 
Fall-back position: If the pediatrician does not indicate a 380.4 diagnosis, you'll lose the $48 associated with in-office billing of 69210 (1.27 transitional total [TT] nonfacility relative value units [RVUs]) -- or the $32.87 for reporting the code in a facility (0.87 TT facility RVUs using the 2007 National Physician Fee Schedule, which represents Medicare equivalent payment). But that doesn't mean the work goes out the window. The AMA via CPT Assistant directs you to capture the wax removal with an E/M code, West says.
 
Example: "A physician under direct otoscopic visualization with the use of a curette does not remove impacted cerumen," says Penelope A. Ritchie, RHIT, quality improvement analyst for St. John's Mercy Medical Group (SJMMG), which operates in the St. Louis metropolitan area. "Should he bill 69210?" she asks.
 
Answer: No. Because the wax was not impacted (see definition on page 34), 69210 is inappropriate. Regardless of removal method, the physician should not use the impacted cerumen removal code, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, a national ENT coding speaker and president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. He should instead use an E/M code (such as 99201-99215, Office or other outpatient visit) to bill for the work.
 
2. Check for Instrumentation

Impacted cerumen goes hand-in-hand with 69210's second requirement: Removal must be by instrumentation. "If the cerumen is truly impacted and the otolaryngologist or primary-care physician removes the cerumen using an otoscope and wax curettes, forceps and/or suction," you may appropriately bill 69210, West says.
 
Impact: Ear lavage doesn't count as 69210, Cobuzzi says. A water pik doesn't meet the code's requirement of using instrumentation by direct visualization to remove impacted cerumen. Although it does make sense that you should be able to bill for the time-intense service of a medical assistant or nurse performing irrigation for impacted cerumen, this would not meet the published guidelines for 69210. 
 
Proper protocol: Think of 69210 as "a failed ear wash requiring a physician's skill." First, staff put in Debrox drops to soften a patient's wax and then use the water pik for the removal. The ear wash fails, and a pediatrician must use tools to remove the impaction. If documentation shows that the impaction removal required the physician's skill, you should use 69210, Cobuzzi says. If the pediatrician then follows up with the water pik, 69210 is still OK.
 
CEU opportunity: A pediatrician under direct otoscopic visualization uses a curette to remove some impacted cerumen and follows up with irrigation. This counts as 69210 because the impaction (380.4) required the physician to go in with instrumentation, Cobuzzi says.