Primary Care Coding Alert

Your best bet for reimbursement is to have two different diagnosis codes. In your case, you could link an appropriate diagnosis code to describe ear congestion (such as 381.81, Dysfunction of Eustachian tube) to the 99212 (Office or other outpatient visit for the evaluation and management of an established patient ) and combine 380.4 (Impacted cerumen) with 69210. Make sure you attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. Also, note that 380.4 is the only diagnosis code Medicare will accept with 69210, and most private payers follow suit.

You have a better chance of reimbursement if your diagnosis code for the office visit is completely different from that of the cerumen removal. For example, if your patient presents with flu-like symptoms and you are able to link 487.1 (Influenza with other respiratory manifestations) to the E/M code, most payers will clearly see the difference between the two services and will reimburse them separately. But, in most cases, you will be using a diagnosis code from the 380-389 series (Diseases of the ear and mastoid process) with the E/M, which may blur the line between the two services.

Documentation plays a paramount role in these cases. The documentation must clearly show the separate nature of the services. After the FP records the history, exam and other elements of the E/M visit, he or she should skip a line, write the word "procedure" and provide a description. The description should include the qualities of the cerumen, how it was removed, how difficult it was to remove, and how the patient tolerated the procedure.

Also, make sure you do not report 69210 for cerumen that is easily removed or if office staff other than the physician or nonphysician practitioner performed or supervised the procedure. This is considered simple cerumen removal and is included in the E/M.

Make sure you check with your local Medicare carrier for restrictions. For example, Florida's First Coast Service Options Inc. will pay for 69210 only if the cerumen removal is done by the manual disimpaction method. It considers irrigation or chemical solvents to loosen the cerumen to be part of the E/M service. Other states may have similar rules.