Pediatric Coding Alert

You finally have a definitive answer to cerumen removal code's requirements

The AMA ends the rash of CPT 69210 interpretations and offers clear-cut guidance on appropriate code use.

You read one article that states a nurse can perform 69210, another that stipulates a physician has to provide the service, and yet another that advises reserving the code for cases involving instrumentation. What and whom should you believe? The AMA now offers its official word.

Test Your 69210 Coding Prowess With 3 Scenarios

Educate your staff on how to code earwax-related encounters--and see if your cerumen coding policy needs updating--with this quick quiz:

Question: Which of the following scenarios should you report with 69210 (Removal impacted cerumen [separate procedure], one or both ears)?

1. A nurse removes earwax via irrigation or lavage.
2. A primary-care physician removes earwax via irrigation or lavage.
3. A patient presents to the office for earwax removal as the chief complaint.

Documentation describes the wax as impacted cerumen because it completely covers the eardrum and causes the child hearing loss. A primary-care physician removes the impacted cerumen with magnification provided by an otoscope and instruments such as wax curettes, forceps and suction.

Answer: Only scenario 3 qualifies as 69210, according to CPT Assistant July 2005.

Describe Impacted Wax Removal With 69210

You should report 69210 for impacted cerumen removal only. That 69210 requires impacted cerumen isn't any surprise. "An impacted cerumen diagnosis (380.4, Impacted cerumen) is the only appropriate diagnosis you can use with 69210," says Catherine A. Hudson, RMA, RPT, office manger at Cumberland Pediatrics PC in Marietta, Ga.

Alternative: If a nurse or pediatrician removes earwax (as in scenarios 1 and 2), you should instead assign the appropriate-level E/M code.

To help staff determine whether a case involves impacted cerumen, use the following definition, offered by the American Academy of Otolaryngology-Head and Neck Surgery. You should consider cerumen "impacted" if any one or more of the following considerations are present:

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

• Qualitative: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching and/or hearing loss.

• Inflammatory: Associated with foul odor, infection or dermatitis.

• Quantitative: Obstructive, copious cerumen that require the physician's skill to remove with magnification and multiple instrumentations.

Reserve 69210 for Physician Instrumentation Work

To use 69210, a physician must remove impacted cerumen using instrumentation. The pediatrician must use, at minimum, an otoscope and instruments, such as wax curettes. The AMA adopted this new policy from many Medicare carriers' guidelines.

"Medicare carriers have always had pretty strict interpretations regarding the payment of 69210," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo. The AMA's new guidance more closely aligns CPT with carriers' policies.

New rule: You should report 69210 when the encounter meets these criteria:

1. the patient has cerumen impaction

2. the removal requires physician work using at least an otoscope and instrumentation, rather than simple lavage.

In the above examples, only scenario 3 meets the two requirements and therefore qualifies for 69210.

Benefit: You'll no longer have to guess how you should interpret 69210. "Having uniform 69210 requirements should make appropriately assigning the code more consistent," says Sharon Newman, CPC, coding education and documentation coordinator at Children's Specialty Group in Norfolk, Va.

Update Your Wax-Removal Policy, if Necessary

How much the new guidelines will affect your practice depends on your current 69210 coding policy. "Our pediatricians assign 69210 only when they use an otoscope and other tools to remove impacted cerumen," Hudson says.

If your office interprets 69210 more loosely, you'll have to redefine your code use. "Now that CPT has narrowed down what qualifies as 69210, physicians may report the code less frequently," Newman speculates.

Also: When you assign 69210, a separate entry should support the procedure, Newman says. "Accompanying documentation should indicate the time, effort, and equipment required to provide the service," states CPT Assistant.