Wiki 69210 vs 69421

bag4498

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Hi all,

I'm new to coding outpatient surgical procedures done in a hospital setting.

1. A patient is having tubes removed under general anesthesia and there is cerumen removed from the same ear. How do I decide which code to use? 69210 OR 69421. I know I can't use both.

2. Does the OP note have to specifically say "impacted cerumen"? I see a lot of notes that say "A copious amount of cerumen was present, which was removed using an alligator forceps and suction through
visualization of the Zeiss microscope". With that verbage, can I use the impacted cerumen requiring instrumentation?

3. how do I know when to include excision of aural polyp when a polyp is removed at the same time as tubes and/or cerumen?

Thanks!!
 
1. 69210 and 69421 are considered inclusive per CCI edits. Unless there is a valid differentiate between the codes such as LT vs RT ear, then you would only bill one. I would recommend billing the 69210 as this is higher paying code.

2. For 69210 to be billed the documentation needs to state that based upon examination using an otoscope or operating microscope the practitioner uses crocodile forceps, an aural speculum, wax hooks, probes of various sizes, and/or a suction device to remove the impacted cerumen under visualization with the patient semi-reclined or in supine position.

3. 69210 and 69421 are both considered inclusive with 69540 per CCI edits. Again, unless there is a differentiate reason such as LT vs RT ear, etc, you would only bill the 69540.
 
1. 69210 and 69421 are considered inclusive per CCI edits. Unless there is a valid differentiate between the codes such as LT vs RT ear, then you would only bill one. I would recommend billing the 69210 as this is higher paying code.

2. For 69210 to be billed the documentation needs to state that based upon examination using an otoscope or operating microscope the practitioner uses crocodile forceps, an aural speculum, wax hooks, probes of various sizes, and/or a suction device to remove the impacted cerumen under visualization with the patient semi-reclined or in supine position.

3. 69210 and 69421 are both considered inclusive with 69540 per CCI edits. Again, unless there is a differentiate reason such as LT vs RT ear, etc, you would only bill the 69540.
1. 69210 and 69421 are considered inclusive per CCI edits. Unless there is a valid differentiate between the codes such as LT vs RT ear, then you would only bill one. I would recommend billing the 69210 as this is higher paying code.

2. For 69210 to be billed the documentation needs to state that based upon examination using an otoscope or operating microscope the practitioner uses crocodile forceps, an aural speculum, wax hooks, probes of various sizes, and/or a suction device to remove the impacted cerumen under visualization with the patient semi-reclined or in supine position.

3. 69210 and 69421 are both considered inclusive with 69540 per CCI edits. Again, unless there is a differentiate reason such as LT vs RT ear, etc, you would only bill the 69540.
1. 69210 and 69421 are considered inclusive per CCI edits. Unless there is a valid differentiate between the codes such as LT vs RT ear, then you would only bill one. I would recommend billing the 69210 as this is higher paying code.

2. For 69210 to be billed the documentation needs to state that based upon examination using an otoscope or operating microscope the practitioner uses crocodile forceps, an aural speculum, wax hooks, probes of various sizes, and/or a suction device to remove the impacted cerumen under visualization with the patient semi-reclined or in supine position.

3. 69210 and 69421 are both considered inclusive with 69540 per CCI edits. Again, unless there is a differentiate reason such as LT vs RT ear, etc, you would only bill the 69540.
Can you tell me where you found the description for the 69210?
 
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