EM Coding Alert

Question: I have been researching new cerumen removal code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral), and I was wondering: When, if ever, might we report a separate E/M with a cerumen removal code?

Louisiana Subscriber 

Answer: The answer depends on the insurer’s policy, as well as how thorough your documentation is, but an example where most payers would reimburse both cerumen removal and an E/M would be if the patient presents with vomiting, throat pain and a fever. The physician examines the patient, and during the examination he notes cerumen that is impacted in the ear. After the E/M, the physician performs cerumen removal with irrigation or instrumentation.

You should be able to report the E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended, because the E/M would not be considered related to the cerumen removal. Then you could report either 69209 or 69210 (Removal impacted cerumen requiring instrumentation, unilateral) for the cerumen removal, depending on encounter specifics. Check the documentation to confirm whether the E/M is significant enough to warrant reporting, and to discover how the provider removed the cerumen.