Pediatric Coding Alert

You can rest assured that claims for 69210 (Removal impacted cerumen [separate procedure], one or both ears) will hold up on chart audit provided you check off these items.

You can only report 69210 with a diagnosis of impacted cerumen (380.4). Removing wax that is not impacted does not justify 69210. Instead, capture this work with an E/M code (99201-99215, Office or Other Outpatient Services) -- no matter how the provider removes the wax.

To determine if documentation supports 384.0, use the definition from the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), which is also published in CPT Assistant July 2005. Consider cerumen clinically "impacted" if any one or more of the following are present:

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

• 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.

• Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.

The AAOHNS and AMA indicate 69210 also requires physician performance and instrumentation. You may report removal with 69210 if performed by a physician using, at minimum, an otoscope and instruments, such as wax curettes or an operating microscope and suction, plus specific ear instruments (for instance, cup forceps and right angles).

The following scenario would warrant the use of 69210: The patient presents to the office for an ear ache. Removal of impacted cerumen is required to visualize the tympanic membrane. The impacted cerumen is removed by the pediatrician with magnification provided by an otoscope and a wax curette.

Code 69210 may be used here because both criteria were met: The patient had cerumen impaction (impairing examination of the tympanic membrane) and the removal required physician work using an otoscope and instrumentation rather than simple lavage.

"Code 69210 is a surgical procedure," says Kris Cuddy, CPC, CIMC, independent consultant in DeWitt, Minn. Accompanying documentation should report the time, effort, and equipment needed to perform the procedure. Cuddy says, "Documentation must include the following:

• the fact that cerumen impaction was observed, along with the location(s)

• the instrumentation used (and any magnification)

• the removal procedure

• the procedure's outcome

• patient care instructions."

Consider ear lavage, which is sometimes confused with cerumen removal, as part of an E/M visit (99201-99215), explains Karen K. Byrne, RN, BS, CPC, CEMC, coding analyst, Carolina Health Specialists, Myrtle Beach, S.C. A nurse can provide the wash. "There is no specific code for lavage including water piks." Doubt that you should count ear washing with 99201-99215? According to the AAOHNS and the AMA, the following scenarios do not justify the use of 69210, despite the significant medical assistant/nursing time and practice expense involved.

Patient scenario 1: The patient presents to the office for the removal of earwax by the nurse via irrigation or lavage. This service is captured by the appropriate E/M code.

Patient scenario 2: The patient presents to the office for the removal of earwax by the primary care physician via irrigation or lavage. This service is also captured with the appropriate E/M code.

"Ear irrigation or ear lavage without any separate provider use of instrumentation should be included in the E/M service selected for that day," Cuddy. "The work performed should be appropriately documented -- no matter which staff member provided the service. Appropriate documentation will allow the provider to include the work in his/her E/M selection."

Heads up: If both ear lavage and instrumentation with an ear curette by the physician are required to remove the cerumen, it is appropriate to code 69210 for the procedure.

Tip: Always provide separate documentation for the impacted cerumen removal procedure. Do not bury it in the E/M note. Coding also requires modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the associated E/M code.