Primary Care Coding Alert

When a patient reports to the family physician (FP) for removal of cerumen (earwax), you'll have to know what payers consider a procedure. There's also a chance the FP will perform cerumen removal in addition to the E/M service, which could mean extra reimbursement for your claim.

Discover the ins and outs of cerumen removal coding with these expert tips:

The scenario sounds like a slam dunk: Patient reports to the FP with earwax, the physician removes it, and coder chooses cerumen removal code ... right?

Not so fast: Some earwax extraction encounters will not reach the 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) level. In order to report a cerumen removal code, the physician has to use direct visualization (via otoscope) and instruments to remove impacted cerumen, says Sandra Pinckney, CPC, coder at CEMS PC in Grand Rapids, Mich.

Example: An 8-year-old established patient reports to the FP; her mother reports the child has had a fever and upper respiratory infection symptoms for three days. While checking for an ear infection, the physician determines that the patient has soft wax in his outer ear.

The physician removes a small amount of soft earwax with a single scoop of the curette. Ultimately, the FP diagnoses the child with tonsillitis and sends him home. The encounter notes indicate an expanded problem focused history and an expanded problem focused examination.

In this instance, the physician did not remove impacted cerumen -- removal of wax from the outer ear is part of the E/M, even when the FP uses an instrument. Therefore, you should include the earwax removal in the E/M service and report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...) for the service with 463 (Acute tonsillitis) appended to represent the patient's tonsillitis.

Check out this excerpt from CPT Assistant, July 2005: "If any one or more of the following are present, cerumen should be considered 'impacted' clinically:

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

• "Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.

• "Inflammatory considerations: Associated with foul odor, infection, or dermatitis.

• "Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills." The methods most commonly employed for cerumen disimpaction are suction, probes, forceps, right angle hooks, and curettes, confirms Jan Allen, claims and accounts receivable manager for a four-physician practice in Santa Paula, Calif.

You cannot use 69210 "if the nurse just flushes out the patient's ear to remove the wax," continues Allen, who offers this scenario.

Example: An established patient reports to the FP saying she cannot hear out of her left ear and it "feels full." The FP uses an otoscope to find copious amounts of hardened wax almost completely blocking the eardrum.

Using right angle hooks, the physician removes the impacted cerumen. On the claim, you'd report 69210 with 380.4 (Impacted cerumen) appended to represent the patient's cerumen.

If the patient reports to the FP for earwax removal, you'll typically choose an E/M code or 69210 for the service. If the physician performs a separately identifiable E/M service, however, be sure to code 69210 and the appropriate-level E/M.

Payout: You'll nab the money for the E/M, as well as about $47 for 69210 (1.30 transitioned nonfacility relative value units [RVUs] multiplied by the temporary 2010 Medicare conversion rate of 36.0846).

As an example, 69210-E/M encounters can happen with "geriatric patients who return for regular visits; diabetes, blood pressure, cholesterol, etc.," Allen shares.

Example: An established patient reports to the FP for a three month follow-up after having started a new medication for his cholesterol. (The patient's blood test results are already with the FP.)

After discussing the cholesterol issue with the patient, he says, "By the way, Doc, I can't hear well out of my right ear."

The FP looks in the ear with an otoscope and sees hardened wax blocking the entire canal; flushing is not a practical option, so the FP extracts the cerumen using suction and forceps.

Since the patient reported to the FP for a cholesterol check, and then the FP removed the cerumen separately, you can code for both. On the claim, report the following:

• 69210 for the cerumen removal;

• the appropriate-level code (99211-99215 Office or other outpatient visit for the evaluation and management of an established patient ...) for the E/M service;

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code to show  that the E/M and cerumen removal were separate services;

• 380.4 appended to 69210 and the E/M code to represent the patient's cerumen; and

• 272.0 (Disorders of lipoid metabolism; pure hypercholesterolemia) appended to the E/M code to represent the patient's cholesterol issue.