Wiki Procedure Code with EM Code

[moc12]

Reviewing an encounter where the provider removed impacted cerumen to right ear via irrigation
CC: Ear pain x 2 days, ICD 10 codes: H61.22 and H66.93. Can CPT code be applied to this visit if the procedure was documented in the note?
Thank you

 

[Chelle-Lynn]

The documentation provided would not be enough to really make a true decision, but based on what you provided, my initial reaction would be no. The procedure is related to the ear wax removal and the diagnosis reflect impacted ear wax and an ear infection. To allow for an E&M with a modifier 25 the services would have to be significant and separate. It does not appear from the information provided that this is the case.

 

[thomas7331]

Agreed, to code an E&M service with this or any procedure, the documentation needs to support a modifier 25, meaning 'significant, separately identifiable evaluation and management service by the same physician' above and beyond the E&M required for the procedure. Just based on the information you have given and without reviewing the documentation, there is no way to definitively determine whether or not this requirement has been met.

 

[Pathos]

That depends on how the earwax procedure was done and medical necessity.

Ear cerumen removal (69209-69210) is generally bundled into any regular outpatient office visit (E/M), unless the provider is using extensive instruments. A simple or regular ear removal should not be carved out of the E/M visit.

According to John Verhovshek from AAPC (posted by Renee Dustman):

"The patient presents to the office for earwax removal, which requires
magnification provided by an otoscope or operating microscope, and instruments
such as wax curettes, forceps, or suction by the primary care physician/provider
or otolaryngologist. This latter situation occurs most commonly when impacted
cerumen completely covers the eardrum and the patient has hearing loss."

AAPC article, same author 2016
AAPC article, same author 2017

Hope that helps!

 

[moc12]

The documentation provided would not be enough to really make a true decision, but based on what you provided, my initial reaction would be no. The procedure is related to the ear wax removal and the diagnosis reflect impacted ear wax and an ear infection. To allow for an E&M with a modifier 25 the services would have to be significant and separate. It does not appear from the information provided that this is the case.

Thank you for your response.