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Wiki Office Visit and Impacted Cerumen

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jenp2005

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I have a patient that saw an NP for follow up from a hospital visit. She also had impacted ceruman which was cleaned out. Can I bill the office visit and 69210?
Thanks,
 
If the follow-up office visit is for something other than the impacted cerumen, and it was more than just an irrigation, then yes, you can bill both. You would put modifier -25 on your E/M.
 
In order to charge 69210, the provider must documented he/she did the removal with instrustment. Also it must be documented that the cerumen is impacted. Here is the Lay Description :
"Under direct visualization, the physician removes impacted cerumen (ear wax) using suction, a cerumen spoon or delicate forceps."
 
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