Primary Care Coding Alert

When your FP removes cerumen, zoom in on the instrumentation and diagnosis to ethically boost practice revenue.

Suppose your FP provides 69210 (Removal of impacted cerumen [separate procedure], one or both ears), but you report 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...). In 2008, 69210 pays about $45 nationally -- compared with about $37 for 99212. That $8 may not seem like much, but over a year it can add up.

Check out this primer on identifying impacted cerumen claims.

The key to proper code choice for cerumen removal lies with the diagnosis and the physician's actions. If the FP removes impacted cerumen with instrumentation, you can report 69210 for the service, says Kent Moore, manager of healthcare financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. If the physician (or a nonphysician practitioner) removes the cerumen with lavages or other solutions, you cannot use 69210.

"Impacted" definition: For coding purposes, "impacted" cerumen is "packed tightly in the outer ear, so much so that the external ear canal is blocked. The ear wax is hard and possibly crusted," says Steve Verno, NREMTP, CMBSI, director of reimbursement at EMS in Hollywood, Fla. Impacted cerumen may block the patient's tympanic membrane or cause hearing loss, Verno says.

According to Moore, if your FP uses one of the following instruments to remove cerumen, the service likely qualifies for 69210:

- suction

- probes

- forceps

- right angle hooks

- wax curettes.

You should use these criteria as a base, but "different carriers may have different policies on cerumen removal. The commonality is that the ear is impacted with cerumen, and the removal is performed by means other than simple lavage and involves a significant process," Verno says.

As an example, Verno notes the 69210 policy for Blue Cross-Blue Shield: "CPT code 69210 is eligible for reimbursement when the following criteria are met: The cerumen removal requires the skill of a physician, or the removal is directly supervised by a physician and the removal requires a significant amount of time and effort."

Example: An established patient presents with problems in his right ear. He says there's been constant ringing in the ear and severe itching in the canal for the past three days.

The FP checks the patient's left ear, which is clear. A right-ear check reveals extreme blockage of canal by crusty hard wax. Due to the obstruction, the FP cannot see the tympanic membrane.

The FP removes a large piece of impacted cerumen using an ear curette and otoscope with large speculum. On the claim, you should report 69210. Also, attach ICD-9 code 380.4 (Impacted cerumen) to 69210 to prove medical necessity for the service.

For some carriers, 380.4 is the only acceptable ICD-9 code for 69210. However, there are carriers that are more lenient on 69210 diagnosis coding.

Kansas Medicare LCD L9422 has 100 different diagnoses that support medical necessity for 69210, Verno says.

Best bet: Check your contracts for specific info on proving medical necessity for 69210.

When the physician removes cerumen without instrumentation, consider the removal a part of the overall E/M service and code accordingly, Verno says.

These cerumen removal encounters will likely result in a level-one or -two E/M, depending on the encounter specifics. For instance, the FP evaluates an established patient's ear and removes a small amount of wax with lavage and cotton swabs. The FP diagnoses the patient with otitis media and places her on antibiotics for the middle ear infection. Notes indicate a level-two E/M.

On the claim, report 99212 for the service (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making).

Remember to link 382.9 (Unspecified otitis media) to 99212 to represent the patient's ear infection.