Quantitative considerations: Obstructive, copious
cerumen that cannot be removed without magnification
and multiple instrumentations requiring physician
skills.”
Q. If the physician removes cerumen as part of the
exam but the cerumen is not impacted, what code would be appropriate?
A. A simplistic answer is that removing the wax is simply
included in the emergency and management
(E/M) code. The actual situation, however, is not quite so
straightforward.
Since real-life medical coding is governed by multiple
entities—including the AMA, CMS, and multiple privatesector
payors—there are many areas of coding where conflicting
interpretations exist. Such ambiguity exists in the application
of the code 69210.
In this example, coders may make at least two interpretations:
If you ask the physician if the wax was “impacted,” he
or she may indicate that, because the cerumen was not
stuck tightly and filling the entire ear canal, the wax was
not “clinically impacted.”
But be careful; you may be asking the wrong question.
Before you give up too easily, ask the physician this
question: “Why did you decide to remove the wax?”
Chances are that the physician will tell you that the wax
was getting in the way of performing an adequate otoscopic
exam of the ear. If so, then the wax actually does
meet the strict AMA coding definition (listed above) for
impacted cerumen.
Since the removal of this “required physician work using
at least an otoscope and instrumentation,” the procedure
could be billable with code 69210.
In some situations, however, using this code according to
the strict AMA definition may still not be appropriate. As
CMS cautioned in the Federal Register of June 29, 2006
(page 37233), “It is our understanding that CPT code
69210 is to be used when there is a substantial amount
of cerumen in the external ear canal that is very difficult
to remove and that impairs the patient’s auditory function.
We will continue to monitor the use of this code for the
appropriate circumstances.”
To stay within the spirit of this definition, it seems
best to avoid using this code for situations that only
take a minute of the physician’s time to scoop out the
wax. Rather, most coders would recommend that code
69210 be reserved for use in situations where the cerumen
removal takes significant effort by the physician.
This is a situation where many individual payors have set different
policies for application of this code, so it is best to check
with individual payors for their policy.
Q. As an urgent care center, can we also bill an office
visit with a 25 modifier and a 69210 on the same
day of service, especially if the doc examines the patient
first and then determines that he needs an ear wash?
Question submitted by Kathy Partenheimer, Medical of Dubois
A. An E/M code may be eligible for reimbursement in addition
to code 69210 if all of the following criteria are met:
1. The patient's condition required a significantly, separately
identifiable E/M service above and beyond the
usual pre-service and post-service care associated with
the removal of the impacted wax
2. The documentation requirements for use of that E/M
code have been met
3. Modifier -25 is attached to the E/M code
When you are using 69210 for ear wax impaction, it is appropriate
to use an E/M code (with modifier -25) if the patient
received a true evaluation and management for a separate
problem (such as bronchitis or pharyngitis) or for
complicating problems (such as dizziness or otitis media). It
is generally a good idea to include patient records with
billings (or at least with appeals) to substantiate the medical
necessity for a separate E/M.
On the other hand, if the patient comes in with a complaint
of a "stuffy ear" and the physician determines that the
patient has a cerumen impaction, removes the wax and
there is no medical necessity for a separate evaluation and
management, then one would code only the 69210.
A few payors require the coder to attach modifier -59 (distinct
procedural service) to the procedure code (69210) and
will not reimburse for the E/M when combined with modifier
-25. Although this idiosyncratic coding requirement is
truly frustrating, it may be the only way to get paid.
As always, check with your payor.
Q. At times, the nurses do an ear wash, and the
physician does not perform any portion of the
work involved in the cerumen removal. Is it appropriate
to bill the 99211 with the 69210?
Question submitted by Kathy Partenheimer, Medical of Dubois
A. Since no physician work was required, you should
not use code 69210. Instead, you would only bill
99211. Because of the liability inherent in an ear wax removal
(especially in the urgent care setting where the patient
is not well known to the physician), I would personally
advise against performing this procedure without a physician
evaluating and documenting the condition of the ear(s)
both before and after the ear lavage.
In this case, the correct E/M code would be a 99212 (or
higher if indicated by medical necessity and documented appropriately),
but it would not be appropriate to use code
69210 unless the procedure required physician work.
Q. If the patient requires removal of impacted cerumen
from both ears, is it appropriate to add
modifier -50 to the code 69210 to indicate that a bilateral
procedure was performed?
A. No. Code 69210 is defined as “removal impacted
cerumen (separate procedure), one or both ears.”
Use this same code only once to indicate that the procedure
was performed, whether it involved removal of impacted
cerumen from one or both ears.
Q. What are the appropriate ICD-9 diagnosis codes
to justify billing for 69210?
A. Medicare accepts many different ICD-9 codes as
“supporting medical necessity.” By definition, however,
69210 always involves the diagnosis of impacted cerumen,
so it seems reasonable to always attach the code for
impacted cerumen (380.4) to the code 69210.
Of course, the physician documentation should clearly
demonstrate the presence of impacted cerumen, as defined
above. If you are attempting to code an E/M code in addition
to code 69210, appropriate coding of an additional diagnosis
is often helpful to reduce denials.
Note: CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.
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David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at
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