Primary Care Coding Alert

Question: One of my providers recently removed an ear piercing, and he documented that “the post was stuck, inflamed, and caused infection in the left ear helix.” He used two hemostats and unscrewed the post. No anesthesia and no incisions were necessary. Which procedure code would fit this best?

AAPC forum participant

Answer: Based on the information you provided, a standard evaluation and management (E/M) code is most appropriate for this encounter rather than a procedure code. The physician evaluated the patient’s condition, observed the inflammation and the infection, and was able to manage the problem without anesthesia or surgical intervention. Typically, this work is included in an E/M service, which is coded as 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient…). Which E/M code you use will depend on whether the patient was new or established, and on either the medical decision making (MDM) involved or the time the physician spent related to the visit on the date of the encounter (including time spent before and after seeing the patient).