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Patient was scheduled for cerumen removal 69210, however when she presented she had no wax - only some gunk on visualization with microscope. Can't we bill an E&M in addition to the 92504?
Per the CPT Guidelines, under Special Otorhinolaryngologic Services, Diagnostic or treatment procedures that are reported as evaluation and management services (eg: otoscopy, anterior rhinoscopy, tuning fork test, REMOVAL OF NON-IMPACTED CERUMEN) are not reported separately.
I would say you would only be able to charge the 92504 D/T the guidelines.
I hope this helps!