Primary Care Coding Alert

Take this test to see if your cerumen removal guidelines require updating

The AMA silences consultants- various interpretations on 69210 with clear-cut directives on the code's requirement.

One article states a nurse can perform 69210, another stipulates a physician has to provide the service, and yet another advises reserving the code for cases involving instrumentation. What and whom should you believe? CPT Assistant comes to the rescue.

Check Your 69210 Coding Aptitude With 3 Scenarios

Educate your staff on how to code ear-wax-related encounters--and see if your cerumen coding policy needs updating--with this quick quiz:

Question: Which of the following scenarios should you report with 69210 (Removal impacted cerumen [separate procedure], one or both ears)?

1. A nurse removes earwax via irrigation or lavage.

2. A primary-care physician removes earwax via irrigation or lavage.

3. A patient with earwax as the chief complaint presents to the office. Documentation describes the wax as impacted cerumen because it completely covers the eardrum and causes the patient hearing loss. A primary-care physician removes the impacted cerumen with magnification provided by an otoscope and instruments such as wax curettes, forceps and suction.

Answer: Only scenario 3 qualifies as 69210, according to CPT Assistant July 2005. You should report 69210 for impacted cerumen removal only. 

Alternative: If a nurse or family physician removes earwax, as in scenarios 1 and 2, you should instead include the work in the appropriate-level E/M code. -CPT 69210's clarification will have a big impact on physicians and coders,- says Linda Weiss, billing and coding specialist at Seattle Primary Physicians. Hopefully, the AMA will eventually create an -ear irrigation- code to identify the procedure's work component as separate from the E/M service, she adds.

To help staff determine whether a case involves impacted cerumen (380.4, Impacted cerumen), use the following definition, offered by the American Academy of Otolaryngology-Head and Neck Surgery. You should consider cerumen impacted if any one or more of the following conditions are present:

- Visual: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.

- Qualitative: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching and/or hearing loss.

- Inflammatory: Associated with foul odor, infection, or dermatitis.

- Quantitative: Obstructive, copious cerumen that require a physician's skill to remove with magnification and multiple instrumentations.

Limit 69210 to Cases Involving FP Using Instrument

To assign 69210, a physician must remove impacted cerumen using instrumentation. The FP must use, at minimum, an otoscope and instruments, such as wax curettes. The AMA's clarification mirrors many Medicare carriers- guidelines.

-Medicare carriers have always had pretty strict interpretations regarding the payment of 69210,- says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo. The AMA's new guidance more closely aligns CPT with carriers- policies.

New rule: You should report 69210 when the encounter meets these criteria:

1. the patient has cerumen impaction

2. the removal requires physician work using at least an otoscope and instrumentation, rather than simple lavage.

In the above examples, only scenario 3 meets the two requirements and therefore qualifies for 69210.

Benefit: You-ll no longer have to guess how you should interpret 69210. -Finally, we have definite guidelines- that should make appropriately assigning the code more consistent,- Weiss says.

Consider Revising Your Cerumen Removal Policy

How much the new guidelines will impact your practice depends on your current 69210 coding policy. -Even when reporting claims to private payers, we follow Medicare's coding guidelines,- says Mary L. Bonacci, MBA, CPC, at Johns Hopkins University in Baltimore, Md.

If your office interprets 69210 more loosely, you-ll have to redefine your code use. -Now that CPT has narrowed down what qualifies as 69210, physicians may report the code less frequently,- says Sharon Newman, CPC, a coding education and documentation coordinator in Norfolk, Va.

Remember When you assign 69210, you should have a separate entry from the physician to support the procedure, Newman says. -Accompanying documentation should indicate the time, effort and equipment required to provide the service,- states CPT Assistant.