Pediatric Coding Alert

Plus: AMA 'Evaluating ICD-11' As ICD-9 Alternative

Currently, you have one way to report impacted cerumen, but that will change when ICD-10 goes into effect. You will have to scan your physician's notes to determine where this condition occurs.

Impacted cerumen, otherwise known as wax in the ear, can affect both children and adults. The condition occurs when layers of wax within the ear canal build up in the point of blocking the canal and putting pressure on the eardrum. Cerumen is most likely to become impacted when it is pushed against the eardrum by objects people put in their ears, or when it is trapped against the eardrum by a hearing aid. Less common causes include overproduction of earwax or an abnormally narrow ear canal that tends to trap the wax.

Partial loss of hearing is the most important symptom of cerumen impaction. Other symptoms can be itching, tinnitus (noise or ringing in the ears), a sensation of fullness in the ear, and pain in the ear (otalgia). In children younger than one year, cerumen impaction is sometimes discovered during a routine check-up when the doctor finds that the earwax is blocking his or her view of the eardrum.

ICD-9-CM: ICD-9-CM provides a single diagnosis code for impacted cerumen: 380.4 (Impacted cerumen). The ICD-9 manual also directs you to report an additional external cause code, if applicable, to identify the cause of the ear condition.

ICD-10-CM: Look to the H61.2- (Impacted cerumen) series of codes. The fourth digit will specify the affected ear:

• H61.20, Impacted cerumen, unspecified ear
• H61.21, Impacted cerumen, right ear
• H61.22, Impacted cerumen, left ear
• H61.23, Impacted cerumen, bilateral

Documentation: Pediatricians typically make a diagnosis of impacted cerumen by examining the patient's ear canal and eardrum with an otoscope. Irrigation is the most common method of removing impacted cerumen; the process involves washing out the ear canal with water from a commercial irrigator or a syringe with a catheter attached.

If irrigation is not an option or if it fails to remove the cerumen, the physician can remove the wax with a vacuum device or curette (a small, scoop-shaped instrument). The physician uses the curette to ease the impacted wax away from the sides of the ear canal. This ear wax removed by the physician using instrumentation and direct visualization is consistent with CPT® code 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) for the procedure. This code cannot be used for irrigation only.

Physicians will need to be more detailed in their documentation of impacted cerumen by noting which ear is affected.

Coder Tips: Check the chart documentation regarding the tactic used for wax removal and the provider who performed the procedure. Those factors won't change the diagnosis code you report, but will guide which CPT® procedure code you report.

On your superbill, list each of the available diagnosis options for impacted cerumen to prompt the physician to enter the necessary information. Let your practitioners know that they will need to include details regarding which ear has impacted cerumen so you don't have to report the 'unspecified' diagnosis. Abbreviated options on your superbill could include:

• XXXXXX, Imp cerumen, unspec
• XXXXXX, Imp cerumen, R
• XXXXXX, Imp cerumen, L
• XXXXXX, Imp cerumen, bilat.

Keep An Ear Open for ICD-11 Chatter

The American Medical Association (AMA) has made no secret of the fact that it is less than enthralled with the proposition of adopting ICD-10 as the new diagnosis coding system. Not only did the AMA's House of Delegates vote last year to repeal ICD-10 (which CMS did not adopt), but the group also applauded the news earlier this year that ICD-10 would be delayed from its original implementation date of October 2013.

Now the AMA has taken additional steps to express its disillusionment with ICD-10, announcing on June 19 that its House of Delegates adopted a policy to evaluate ICD-11 as a potential "alternative" to replace ICD-9, an AMA news release noted.

"ICD-10 coding will create unnecessary and significant financial and administrative burdens for physicians," said AMA President-elect Ardis Dee Hoven, MD in a June 19 statement. "It is critical to evaluate alternatives to ICD-9 that will make for a less cumbersome transition for physicians and allow physicians to focus on their primary priority - patient care. AMA voted today to consider ICD-11 as a possible alternative. The policy also asks the AMA and other stakeholders, such as the Centers for Medicare and Medicaid Services, to examine other options."

Keep an eye on Pediatric Coding Alert for more on the potential ICD-10 delay.