Wiki 69209 and 69210

[PennyG]

I am coding a removal of impacted cerumen using instrumentation where the provider was unable to remove all of the cerumen. Is having the patient use debrox and warm compresses and then come back in. My question is, is it appropriate to bill the 63909 and/or 69210 if there is not complete removal? Because the code descriptors state "Removal impacted cerumen"

 

[cdnred1360]

Documentation states that the physician personally removed a small portion of impacted cerumen with a curette. However, the remainder could not be removed because it was too hard. The guideline states he should document how much time and the resources used to remove the cerumen. Should we code 69210 with mod 52 or not code it at all?

Answer:

Code the impacted cerumen removal (69210, Removal impacted cerumen (separate procedure), one or both ears) appended with modifier 53 (Discontinued procedure). Modifier 52 (Reduced services) is for when the physician or patient chooses to provide/have only part of a service. For instance, modifier 52 describes the physician's decision prior to providing an inherently bilateral service to perform it unilaterally.

In contrast, if the physician starts the service and then elects to not continue the service due to unexpected complications, modifier 53 is appropriate. That is, the physician intends to provide the complete service but cannot do so due to unusual or extenuating circumstances.

In your example, the physician started and intended to complete a full impacted cerumen removal but due to unforeseen circumstances could not complete it. Therefore, modifier 53 would be more applicable.