Primary Care Coding Alert
Method Provides Coding Clues on Ear FBR
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 of the procedure or other service) appended to show the E/M and FB removal were separate services " 931 (Foreign body in ear) appended to 69200 and the E/M code to represent the FB.
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