Pediatric Coding Alert

Question: A child presents with a foreign body in his ear. An ear plug had broken off in the ear canal. My doctor tries to remove the earplug with lavage and curette but is unable to remove it all. So, he refers the patient to an otolaryngologist. Should I report an office visit in addition to 69200? Also, should I append modifier -53 to 69200?

Michigan Subscriber Answer: Code 69200 (Removal foreign body from external auditory canal; without general anesthesia) is not a starred procedure. Therefore, unless the pediatrician performs a separately identifiable service, you should not report an office visit (99212-99215, Office or other outpatient visit for the E/M of an established patient). But if the physician treats the patient on an emergency basis, you should also use 99058 (Office services provided on an emergency basis).

You should append modifier -53 (Discontinued procedure) to the foreign-body removal code (69200). Modifier -53 indicates that the physician elected to terminate the procedure due to extenuating circumstances. In your situation, the pediatrician discontinues the removal because she is unable to remove all the material. Thus, she deserves credit for her work, albeit unsuccessful. Some pediatricians do not want to bill for incomplete procedures, but it is appropriate.