Primary Care Coding Alert

Choose an E/M instead if the cerumen is not impacted

When the FP performs cerumen (earwax) removal on a patient, coders should resist the urge to choose the surgical removal code without considering the specifics of the encounter.

Why? Coders must look at each encounter separately in order to properly report 69210 (Removal impacted cerumen [separate procedure], one or both ears). Before choosing this code, you have to prove that the cerumen required instrumentation and physician involvement. For treatments that do not meet 69210 criteria, you-ll have to choose another coding strategy.

Check out this advice on when to pick 69210 -- and when to search for another coding option.

Determine Whether Cerumen Is Impacted

When considering 69210, you first need to find evidence that your physician removed impacted cerumen with instrumentation. If he removes the cerumen without instrumentation, you cannot report 69210.

-Impacted means the ear wax 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.

Also, the physician has to perform the procedure with some type of instrumentation to report 69210. On your 69210 claims, most carriers want to see evidence that the physician performed the disimpaction under direct visualization using one of the following methods:

 - suction

 - probes

 - right angle hooks

 - 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 irrigation or lavage, and involves a significant process,- Verno says. Your best bet is to check with your insurers for the specifics on their policies for 69210.

Example: A patient presents saying he has not been able to hear out of his right ear for the past four days; the patient also reports severe itching in the ear and a constant ringing. During the exam, the FP checks the ear canal and the middle of the left ear -- both are clear. But the FP cannot examine the right ear due to extreme blockage of the canal by crusty wax. Further, she cannot visualize the tympanic membrane due to blockage.

The FP removes a large piece of impacted cerumen using a curette and otoscope with large speculum. Upon re-examination of the right ear, the FP finds the blockage is clear, and the ear canal appears red and inflamed. The physician can now visualize the tympanic membrane, and the middle of the right ear is clear.

Solution: In this scenario, the physician satisfied the requirements for the cerumen removal code. Report 69210 for the procedure. Don't forget to link ICD-9 code 380.4 (Impacted cerumen) to 69210 to represent the impacted cerumen.

Many carriers see 380.4 as the only acceptable ICD-9 code for 69210. But check your insurers- policies to be sure because some payers will accept other diagnoses for 69210, Verno says.

-For example, Kansas Medicare has 100 different diagnoses that support medical necessity for 69210,- Verno says.

When to Opt for an E/M Code 
 
So what should you do on cerumen removal claims when you cannot find evidence of instrumentation or physician involvement? Rely on your evaluation and management codes, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Scenarios that you-d code with an E/M might involve simple irrigation with a minor amount of removal. Most carriers consider these removal methods incidental to an E/M visit, says Verno, who recommends that you check your payer policies to be sure you-re coding the cerumen removal correctly.

Example: A 6-year-old patient reports to the FP; her mother says she has a cold. During the exam, the FP finds inflammation in the middle left ear. The physician removes a small amount of non-impacted wax with a single pass of the curette from the middle ear. The patient is diagnosed with otitis media and then placed on antibiotics for the middle ear infection.

In this scenario, you should report an E/M instead of 69210. On the claim:

 - report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M.

 - link 382.9 (Unspecified otitis media) to 99213 to represent the patient's earwax.