Primary Care Coding Alert

If your family physician (FP) isn't using instrumentation to remove cerumen, you might have to pay back $45 or more for each violation.
 
Family practices use several methods, including irrigation, solvents and manual disimpaction, to remove cerumen. Ancillary staff may use some of these methods, which means that many practices are unsure about which cerumen removal service qualifies for 69210 (Removal impacted cerumen [separate procedure], one or both ears) and who can perform the service. "I have been told that only the physician or a nonphysician practitioner (NPP) can perform 69210," says Tony Bell, office manager for Chillicothe Family Physicians in Chillicothe, Ohio. "In addition, I've been told that you should only charge 69210 if the physician/NP had to really work at getting the cerumen out." For instance, if the doctor uses a spoon, you shouldn't bill 69210 .
 
Use 69210 for Physician Manual Disimpaction

You should only report 69210 when a physician uses instrumentation to remove cerumen, says Sherry Moss, a family physician consultant with Spectrum Business Systems Inc. in Fort Lauderdale, Fla. "Many FPs don't want to hear what 69210 really entails," she adds.
 
Code 69210 describes manual disimpaction, which requires a physician's skill. In the Coders' Desk Reference (CDR) eighth edition, CPT's description of 69210 states that "under direct visualization, the physician removes impacted cerumen (ear wax) using suction, a cerumen spoon or delicate forceps," Moss says. That means the FP really has to "dig out the ear wax" to bill 69210, she says.
 
Correct 69210 coding example: For instance, the FP may view the patient's ear using binocular magnification and grasp the cerumen plug with forceps. In this case, Florida Medicare's local medical review policy (LMRP) indicates that you should bill 69210.

Count Lavage and Solvents as E/M

When a provider uses ear-canal irrigation or chemical solvents, however, you would not report 69210, according to numerous Medicare LMRPs, as well as the AMA's CDR.
 
Softening-agent scenario: For instance, a nurse uses a softening agent to soften a 65-year-old Medicare patient's ear wax. Because the nurse performs the service and the removal does not require instrumentation, you should not report 69210 in this case, Moss says. You  should instead report the appropriate E/M service, Florida's Medicare LMRP states.
 
"If the doctor does not see the patient, report a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient ... typically 5 minutes are spent performing or supervising these services) for the service," says Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City.
 
But if the FP sees the patient and orders the nurse-performed cerumen removal, you may bill a higher-level E/M code (such as 99212 ... physicians typically spend 10 minutes face-to-face with the patient and/or family), Fick says. Do not separately report the time the nurse spends removing the wax, he says. Many FPs think the extra $16 reimbursement for coding 99212 instead of 99211 is not enough to warrant seeing patients prior to cerumen removal, he adds.
 
Note: Rates are based on the 2003 National Physician Fee Schedule Relative Value File.