ED Coding and Reimbursement Alert

Question: Our ED wants to report on the physician quality reporting initiative (PQRI) measure 92: Acute Otitis Externa -- Pain Assessment. A 66-year-old patient reports to the ED saying he has a severe right earache; he says it's been going on for three days and rates the pain at 8 on a scale of 10; he also complains of itching and hearing loss in the affected ear. The physician performs an expanded problem focused history and exam, noting "dry, hard cerumen/R canal blocking tympanic membrane." The physician diagnoses supprative otitis media along with impacted cerumen; notes reflect moderate medical decision making. Using saline irrigation and curettes, the physician removes the cerumen and sends the patient home.

Can I report the PQRI code?

Florida Subscriber

Answer: No, you can not report the PQRI code, as the ED E/Ms are not part of the denominator for the PQRI measure 92. To report this measure, you need: A patient greater than 2 years old an diagnosis supporting acute otitis externa, including:

• 380.10, 380.11, 380.12, 380.13, and 380.22
• E/M office visit code 99201-99205 (Office or other outpatient visit for the evaluation of a new patient, which requires these 3 key components: ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: ...). The ED E/M code you would use for this encounter is not in the denominator, so you would cannot report the PQRI code.
• For this claim, report the following:
• 69210 (Removal impacted cerumen [separate procedure],1 or both ears) for the cerumen removal
• 380.4 (Impacted cerumen) appended to 69210 to represent the impacted cerumen
• 99283 (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 moderate complexity ...) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service on the by the same physician on the same day of the procedure or other service) appended to 99283 to show that the E/M and cerumen removal were separate services
• 382.00 (Acute supprative otitis media without spontaneous rupture of ear drum) appended to 99283 to represent the patient's otitis media.