Primary Care Coding Alert

Question: Our physician saw an established patient for an ear infection, but she had such thick cerumen in her ear that he had to remove it first. Can we report cerumen removal and an E/M code?

Kansas Subscriber Answer: 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. Reporting different diagnoses for the two services will help establish the significant, separately identifiable nature of the E/M service. Otherwise, payers may include the E/M with the cerumen removal.

For instance, a patient has a bulging ear drum, but an impaction prevents the physician from examining the ear drum. You would link the cerumen removal (69210) to the impacted cerumen diagnosis (380.4, Impacted cerumen), and link 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). 

Answers to You Be the Coder and Reader Questions reviewed by Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.