Primary Care Coding Alert

Question:Documentation states that the physician personally removed a small portion of impacted cerumen with a curette. However, the remainder could not be removed because it was too hard. The guideline states he should document how much time and the resources used to remove the cerumen. Should we code 69210 with mod 52 or not code it at all?Codify MemberAnswer:Code the impacted cerumen removal (69210, Removal impacted cerumen (separate procedure), one or both ears) appended with modifier 53 (Discontinued procedure). Modifier 52 (Reduced services) is for when the physician or patient chooses to provide/have only part of a service. For instance, modifier 52 describes the physician's decision prior to providing an inherently bilateral service to perform it unilaterally.In contrast, if the physician starts the service and then elects to not continue the service due to unexpected complications that place the patient at unacceptable risk, modifier 53 is appropriate. That is, the [...]