Primary Care Coding Alert

Answer: According to Debra Triplett, CPC, office manager for Hummer Family Practice in Elkins, W.Va., you can code for an office visit, 99211 (office or outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician) or 99212-99215 (office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: ranging from a problem-focused to a comprehensive history; a problem-focused to a comprehensive examination; and a straightforward medical decision to one of high complexity) along with a -25 modifier (significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if you have addressed another problem for the patientbesides just the ear washsuch as monitoring diabetes or hypertension.

Select the level of service and document it appropriately. In addition, you may code for the ear wash, 69210 (removal impacted cerumen [separate procedure] one or both ears). If the only procedure done, however, is the ear wax removal, you may only code 69210.

A reminder to coders from Andrea Lamb, CPC, billing clerk at Upshor Medical Management Services, an 11-doctor managed group practice in Buckhannon, W.Va.clearly document the E/M service first and then specifically record the ear wash. Sometimes coders forget to bill the E/M service when the patient comes in for an ear wash and the FP ends up discussing other problems, Lamb says.