Pediatric Coding Alert

Question: I enjoyed your article on the new cerumen removal code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) (Pediatric Coding Alert Vol. 19, no. 3), but I have a follow-up question. Under what condition would billing an E/M be applicable with this code?

Answer: The answer depends on the insurer’s policy, as well as how thorough your documentation is, but an example where most payers would reimburse both cerumen removal and an E/M would be if the patient presents with vomiting, throat pain and a fever. The doctor examines the patient, and during the examination he notes cerumen that is impacted in the ear so he performs cerumen removal with irrigation or instrumentation. The patient is diagnosed with strep throat.

The E/M should be billable with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) because it would not be considered related to the cerumen removal, and then you could separately report 69209 if done by lavage or 69210 if performed by curette.