Primary Care Coding Alert

Look for opportunities to report E/M with cerumen removal.

When your clinician performs removal of cerumen from the ear, you should know when to use the appropriate CPT^® codes for the procedure and when to include the procedure in the E/M code that you are reporting.

Read the following four scenarios and see if you can crack the coding for these different cerumen removal situations.

Scenario 1: Simple Cerumen Removal by Irrigation

Your FP reviews an 18-year-old established female patient with complaints of blockage of the ears on both sides. Upon examination, your clinician notes that the patient does not have any other signs and symptoms and has no signs of infection in the ears. Upon examination, your clinician also notes the presence of cerumen, which he clears by irrigation. Which of the following codes will you report for the encounter?

     1) Appropriate established E/M code
     2) 69209
     3) 69209-50
     4) 69210

Scenario 2: Bilateral Cerumen Removal

Your FP reviews a 36-year-old established male patient with complaints of fever and blockage of the ear on both sides. Upon examination, your clinician notes presence of impacted cerumen and removes the cerumen using irrigation on the left ear and using an alligator forceps in the right ear. Which of the following codes will you report for the encounter?

     1) 69209
     2) 69210
     3) 69209, 69210-59
     4) 69210, 69209-59

Scenario 3: Cerumen Removal during Unrelated E/M

Your FP reviews a 59-year-old established male patient with complaints of severe tingling and numbness in the lower limbs. Since the patient is under the care of your clinician for diabetes mellitus, your clinician evaluates the patient for his blood sugar levels and adjusts the medications that have been prescribed. During the encounter, as the patient also complained of some blockage in the right ear, your clinician examined the ears and notes the presence of impacted cerumen in the right ear and removes it by irrigation. Which of the following codes will you report for the encounter?

     1) Established patient E/M code
     2) 69209
     3) 69209, E/M code
     4) 69209, E/M code with modifier 25

Scenario 4: Injection Administration and Cerumen Removal

Your FP reviews a 42-year-old established female patient with complaints of blockage of the left ear. The patient is afebrile with no other symptoms. Your clinician examines the patient’s ears, notes impacted cerumen in the left ear, and removes it by instrumentation. Since the patient is also due for her monthly B-12 injection for B-12 deficiency, your clinician administers the injection during the same visit. Which of the following codes will you report for the encounter?

     1) 69210
     2) 69210, E/M code with modifier 25
     3) 69210, 96372-59, J3420
     4) 69210-59, 96372, J3420