Pediatric Coding Alert

Question: A patient presented with ear pain. The doctor used a curette to remove impacted cerumen before being able to visualize tympanic membranes. He diagnosed an ear infection. Can we bill an office visit and modifier along with 69210?

Michigan Subscriber

Answer: Theoretically, you don't need a modifier, though some insurers insist on it. Start by billing the appropriate E/M from 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) and 69210 (Removal impacted cerumen [separate procedure], 1 or both ears). Include diagnosis 380.4 (Impacted cerumen). If the payer rejects your claim, resubmit the E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Caution: Before reporting 69210, verify there was true impacted cerumen (blocking the pediatrician's view of the tympanic membrane) and the physician used instrumentation and direct visualization to remove it. Also ensure that you have the separate documentation of the E/M service and procedure to support the code. Some practices overuse 69210, which means many insurers don't recognize or compensate for it.