Primary Care Coding Alert

Hint: Procedures, providers, and Dx are key.

Cerumen, or earwax as it is more commonly known, is a secretion that occurs in the auditory canal, where it protects, lubricates, and cleans the skin. Occasionally, the ear produces too much of the fluid. When that happens to a patient, your provider may be called upon to remove it.

“Cerumen removal is the most common ear, nose, and throat (ENT) procedure performed in primary care,” say authors Daniel F. McCarter, Ursulla Courtney, and Susan Pollart, writing in American Family Physician. “Approximately 4 percent of primary care patients will consult their physician for cerumen impaction,” the authors go on to say (Source: www.aafp.org/afp/2007/0515/p1523.html).

The article shows that there is a need for accurate cerumen removal reporting in primary care coding. So, we’ve created this handy, four-step guide for you to use the next time your practice provides this valuable patient service.

Step 1: Know if the Cerumen Is Impacted

If your provider documents removal of cerumen from a patient’s ear, but there is no indication that the cerumen was impacted, “you would not use either of the CPT^® codes specifically for impacted cerumen,” says Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas. “Instead, you would code using the appropriate evaluation and management [E/M] service,” Charles adds.

This agrees with CPT^® guidelines, which state, in part, that “for cerumen removal that is not impacted, see E/M service code.” This means you would choose the appropriate E/M code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) for removal in the office of cerumen that your provider has not documented as impacted.

Step 2: Know the Procedure Provider Uses

Impacted cerumen is often identified as having any of the following:

• 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 (Source: CPT^® Assistant, Oct. 13:14).

“Your provider will document the cerumen is impacted if it impairs an exam of the middle ear, auditory canal, or tympanic membrane, or if it is so hard or obstructive that it causes pain or hearing loss,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

When that happens, your provider may choose one of two methods for removal:

• 69209 — Removal impacted cerumen using irrigation/lavage, unilateral
• 69210 — Removal impacted cerumen requiring instrumentation, unilateral.

“The main difference between these two codes is the technique used to remove the impacted cerumen,” says Charles. “69209 should be used if the impacted cerumen was removed using irrigation/lavage, while 69210 should be used if the impacted cerumen was removed using instrumentation such as an otoscope, wax curettes, or wire loops.”

“You could also use G0268 [Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing],” notes Falbo, reminding coders that the code was created, and should only be used, when the physician removes the impaction on the same day that an audiologist has attempted to test for a patient’s audiologic function.

Coding alert: Per their descriptors, both 69209 and 69210 are unilateral procedures. Should your provider remove impacted cerumen from both ears using 69209, you will need to append modifier 50 (Bilateral procedure) to the procedure or follow payer guidelines to indicate that both ears were involved.

“This rule changes for 69210 when billed to Medicare,” Falbo notes. “CMS bases work relative value units [RVUs] for 69210 on it being performed bilaterally, so you can only bill one unit of the service, whether it is performed unilaterally or bilaterally,” Falbo continues. For reporting 69210 bilaterally to payers other than Medicare, you will need to append modifier 50 to the procedure or follow payer guidelines to indicate that both ears were involved, just as you do with 69209.

Step 3: Know Who Performed the Procedure

“Trained professional staff — for example, a nurse or a medical assistant — can perform simple removal via irrigation/lavage [69209], but it must be performed under the appropriate level of supervision ofthe physician or other qualified healthcare professional,” says Charles. “If the removal is more complex requiring instrumentation [69210], or if the patient experiences hearing loss, that should be performed by the physician or other qualified healthcare professional such as a nurse practitioner or a physician assistant,” Charles reminds coders.

Step 4: Know the Correct Dx Code to Use

The cerumen impaction ICD-10-CM codes that support reporting 69210 and 69209 for the removal include the following:

• H61.20 — Impacted cerumen, unspecified ear
• H61.21 — Impacted cerumen, right ear
• H61.22 — Impacted cerumen, left ear
• H61.23 — Impacted cerumen, bilateral.

However, these are not the only ICD-10-CM codes you might use in this situation. Removal of impacted cerumen may allow definitive diagnosis of an underlying problem, for which you could use diagnoses such as H65.- (Nonsuppurative otitis media), H66.- (Suppurative and unspecified otitis media), or H92.- (Otalgia and effusion of ear) to support an E/M code.

Putting it All Together

Suppose that your provider examines a patient complaining of ear pain and finds that impacted cerumen is blocking the patient’s right ear, preventing a full exam of the ear canal and ear drum. Using a curette, the physician removes the impacted cerumen, which enables an exam leading to a diagnosis of acute serous otitis media in the right ear.

You would document this encounter with H65.01 (Acute serous otitis media, right ear) supporting an E/M code from 99201-99215 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) attached, and H61.21 with 69210.