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Primary Care Coding Alert

READER QUESTIONS:

Method Provides Coding Clues on Ear FBR

Published on Tue May 26, 2009

Question: A father brings his 2-year-old son in to the FP with an injury to his right ear; the boy was itching at the ear, which appears swollen and red. The FP visualizes a foreign body (FB) in the external ear, and then performs irrigation to flush out the object (no mention of anesthesia). The FB was a piece of gravel from a fish tank. Can I code the procedure separately, or is it considered part of the E/M? Massachusetts Subscriber Answer: Based on your description, you should be able to report an E/M and a procedure code for this scenario. On the claim, report the following: " 69200 (Removal foreign body from external auditory canal; without general anesthesia) for the FB removal " the appropriate E/M code based on encounter notes with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day [...]
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