ED Coding and Reimbursement Alert

If cerumen is non-impacted, opt for E/M.

When patient's report to the ED with painful, infected or impacted earwax, coders are often left scratching their heads when considering whether to code a cerumen removal procedure code or an E/M service.

The answer: It depends. Some cerumen removal will warrant a separate CPT code, but there will be instances in which you'll roll the service into the overall E/M level.

Know the difference by checking out this cerumen removal FAQ:

When Can You Report 69210?

In order to code cerumen removal with 69210 (Removal impacted cerumen [separate procedure], 1 or both ears), the physician must perform manual disimpaction under direct visualization, explains Joshua Tepperberg, CPC, EMT-D, coding team leader at Caduceus Inc. in New York City.

Also: To code 69210, the physician must remove the impacted cerumen using one of the following methods:

• suction,
• probes,
• forceps,
• curettes, or
• right angle hooks.

"Flushing the ear afterward is sometimes performed [during 69210 service] when there is no infection noted," says Sandra Pinckney, CPC, PCS, office manager at Certified Emergency Medicine Specialists in Grand Rapids, Mich.

What's the Difference Between Impacted and Non-Impacted Cerumen?

When trying to decide if the patient has impacted cerumen, Pinckney relies on the AMA/AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) definition, printed originally in CPT Assistant, July 2005/Vol. 15, Issue 7:

"If any one or more of the following are present, cerumen should be considered 'impacted' clinically:

1. Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane or middle ear condition.

2. Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc., . Inflammatory considerations: Associated with foul odor, infection or dermatitis.

4. Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills." If the patient suffers from any of the above conditions, she likely has impacted cerumen, which you'd represent with 380.4 (Disorders of external ear; impacted cerumen).

How Can I Code ID ED E/M Earwax Removal Encounters?

If the physician removes cerumen that is not impacted, or without using visualization and one of the above-listed methods, report the appropriate level E/M (99281-99285) instead of 69210.

Do this: "Be sure to look for a removal method that is more than simple lavage," Pinckney recommends.

What Are the Characteristics of a 69210 Encounter?

In order to spot 69210 claims each time, Pinckney recommends coders be on the lookout for the following terms in the notes:

• "hearing loss,"
• "cerumen fully occludes visualization of the tympanum,"
• "cerumen has foul odor."

Example: A patient reports to the ED complaining of hearing loss, headache, nausea without vomiting, and "strange stuff" leaking from his right ear. The ED physician performs a leveltwo E/M service, during which he cannot see the tympanic membrane due to crusty, pus-pocked earwax. Under direct visualization, the physician identifies impacted cerumen in the right ear canal. Using suction to clean up the pus and curettes to carve out the hard wax, the physician removes the cerumen. The physician then flushes the ear, provides bandages, recommends over the counter ear drops and sends the patient home.

On the claim, you'd report the following:

• 69210 for the cerumen removal
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity) for the ED E/M service
• 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 99282 to show that the E/M and cerumen removal were separate services
• 380.4 appended to 69210 and 99282 to represent the patient's impacted cerumen
• 784.0 (Symptoms involving head and neck; headache) appended to 99282 to represent the patient's headache
• 787.02 (Symptoms involving digestive system; nausea and vomiting; nausea alone) appended to 99282 to represent the patient's nausea.