Primary Care Coding Alert

69210 or E/M inclusion depends on service and provider. A patient visits your office, complaining of ear pain. The physician orders an ear irrigation. Can you legitimately report 69210 (Removal impacted cerumen [separate procedure], 1 or both ears) for the care? Ask yourself three questions to keep your irrigation claims in the clear. Was It Simply Irrigation? Sometimes a provider can clear the patient's ear with basic irrigation, but sometimes he needs to use more extensive measures. Before choosing 69210, verify the level of service provided. "You cannot bill 69210 if the provider only does irrigation," says Randa Cain, CPC, coding and charge capture supervisor with Martha Jefferson Medical Enterprises/Central Business Office in Charlottesville, Va. "There has to be use of some type of instrumentation to 'dig out' the impaction." "Code 69210 is for removal of impacted cerumen, not an ear irrigation," adds Monica Gourley, CCS, outpatient/inpatient coder with Klickitat [...]