Pediatric Coding Alert

Question: Our pediatrician saw a patient for an ear infection, but the patient had such thick cerumen buildup that he had to remove it first. Can we report both the cerumen removal and the E/M service?


Kansas Subscriber

Answer: If you report just 99212-99215, you could be missing out on an additional $57--69210's approximate going rate.

Lesson learned: Report cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) in addition to a significant, separately identifiable service. Your ICD-9 codes will help you decide whether to code the E/M.

Tip: You must report different diagnoses for the two services. Otherwise, payers will include the E/M with the cerumen removal.

For instance, a child has a bulging ear drum, but an impaction prevents the pediatrician from examining the ear drum. You would link the cerumen removal (69210) to the impacted cerumen diagnosis (380.4, Impacted cerumen) and the office visit (99212-99215 with modifier 25) to the middle-ear-related diagnosis, such as otitis media (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum).

Remember: Coding experts recommend that the pediatrician provide separate notes for the E/M and for the cerumen removal, both of which should clearly describe the separate nature of the services.

Answers to You Be the Coder and Reader Questions were reviewed by Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio; and Victoria S. Jackson, executive director of JCM Inc. in Ladera Ranch, Calif.