Primary Care Coding Alert

Question: Is it appropriate to charge for an evaluation and management (E/M) code in addition to the procedure to remove earwax? The physician must evaluate the patients ear pain or hearing loss to determine the treatment, so our office has been coding and billing both. A representative from our local Medicare carrier told me that we could bill the removal separately only if an instrument was used to remove the cerumen, but not if irrigation was the sole treatment used. Is this correct?

Wyoming Subscriber

Answer: In most instances, family practice coders would bill an E/M service in addition to 69210 (removal impacted cerumen [separate procedure], one or both ears). The E/M code would also be appended with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If the patient has presented with ear pain (388.70, otalgia, unspecified), the physician most likely will conduct a complete evaluation of the ears, nose, throat, neck and lungs to determine if other factors are contributing to the pain. This documented ear, nose and throat (ENT) exam, along with relevant history and/or medical decision-making, would support coding and billing the E/M service.

In other cases, the patient may be seen for reasons unrelated to ear pain or diminished hearing perhaps an annual exam (99381-99387, new patient; or 99391-99397, established patient) or a problem-oriented visit (99201-99205, new patient; or 99211-99215, established patient) to discuss a different condition. For example, the physician discovers a lot of earwax in a 7-year-old patient during an annual checkup. The office would report 99393 (established patient, periodic preventive medicine, late childhood [age 5 though 11 years]) and 69210. Alternately, if an adult scheduled an office visit to have her hypertension checked, the office may assign a low-level E/M code along with the earwax removal code.

The second part of the question use of an instrument like a curette as opposed to irrigation is unusual. Typically, the method used for removing impacted cerumen is not in question. However, it is possible that some carriers have specific limitations. If so, coders should get the directive in writing and then follow it closely.