Pediatric Coding Alert

Question: Our pediatrician removed a small portion of impacted cerumen with a curette. However, he could not remove the remainder because it was too hard. The guideline states he should  document how much time and the resources used to remove the cerumen. Should we code 69210 with modifier 52 or not code it at all?

Codify Member

Answer: Code the impacted cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) and append modifier 53 (Discontinued procedure). Modifier 52 (Reduced services) is for when the physician or patient chooses to provide/have only part of a service. For instance, modifier 52 describes the physician's decision prior to providing an inherently bilateral service to perform it unilaterally.

In contrast, if the physician starts the service and then elects to not continue the service due to unexpected complications that place the patient at unacceptable risk, modifier 53 is appropriate. The physician intended to provide the complete service but cannot do so due to unusual or extenuating circumstances. In your example, the physician started and intended to complete a full impacted cerumen removal but due to unforeseen circumstances could not complete it. Therefore, modifier 53 would be more applicable.