Pediatric Coding Alert

Question: A patient presented to our practice with ear pain, but the pediatrician had to remove impacted cerumen before he could visualize the tympanic membrane. He ended up diagnosing an ear infection. Can we report an office visit and 69210 or should we just stick with the E/M code since the patient didn’t present specifically for an ear wax issue?

Answer: Whether to report 69210 (Removal impacted cerumen requiring instrumentation, unilateral) in instances like this is a delicate issue because if you just flick a little wax aside to visualize the eardrum, you shouldn’t bill for cerumen removal. However, if the earwax removal requires the use of a special device that allows you to remove the cerumen before you can visualize the tympanic membrane, you can report it.

In black and white: The July 2005 CPT^® Assistant states that cerumen is considered “impacted” in several circumstances, one of which is, “cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.” Therefore, if the cerumen is blocking your view and you have to use special instrumentation to remove it above and beyond irrigation, most payers allow you to report 69210.

You should ensure that you have separate documentation of the E/M service and procedure to support reporting both codes. Some practices overuse 69210, which leads many insurers to not recognize or compensate for it.

Modifier advice: When reporting 69210 with an E/M service, you should report the appropriate E/M from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or an established patient ...) 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) appended, along with 69210. Include diagnosis 380.4 (Impacted cerumen) on the 69210 claim, and an ear-related diagnosis (such as 382.00) on the E/M line item. Make sure your physician documents a separate procedure note for the cerumen removal -- don’t bury the procedure in the E/M note.

New for 2014: Although most payers specifically indicated that practitioners had to use instrumentation when removing impacted cerumen to qualify for 69210, CPT^® now follows that lead and puts it right in the code description, with the full descriptor now stating, “Removal of impacted cerumen requiring instrumentation, unilateral.” Therefore, using ear lavage, water pik or ear washings will not qualify for 69210 because they don’t qualify as instrumentation (instead, items like earwax curettes are considered instrumentation).