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Removal of impacted cerumen

  1. #21
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    Medical Coding Books
    Chrissy - yes to your scenario.
    Lisa
    Lisa Bledsoe, CPC, CPMA

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    Chrissy,

    As long as the E/M was medically necessary, then yes, the doctor may bill the E/M and the 69210 performed by him/her with instrumentation.

    Kris

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    Can you please send me the article. We always have questions about this in my office. Thanks so much! My email is cbedwards@hotmail.com
    Cheri Edwards, CPC

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    Yes, will send today.

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    I have a question about this. If the patient comes in for a med check/discuss labs type of thing....and then while she was there, mentioned that she felt her ear was "plugged". The physician finds that it is cerumen impaction and then the nurse enters and does the removal. Can you bill a regular E&M such as 99213 with the dx of HTN (or whatever) and then a 99212 for the procedure using a 25 modifier and cerumen impaction as the dx for that? I realize there would have to be documentation to support it.

  6. Default
    I have a question about this. If the patient comes in for a med check/discuss labs type of thing....and then while she was there, mentioned that she felt her ear was "plugged". The physician finds that it is cerumen impaction and then the nurse enters and does the removal. Can you bill a regular E&M such as 99213 with the dx of HTN (or whatever) and then a 99212 for the procedure using a 25 modifier and cerumen impaction as the dx for that? I realize there would have to be documentation to support it.
    Unfortunately, only one E/M office visit service may be billed at each date of service. The nurse/ancillary staff performing the ear irrigation (presumably), should document his/her services and the outcome into the chart note. The provider who performed the E/M, or the coder, would then use that documentation along with the provider's documentation to determine one single E/M level for the entire visit.

    Now, if the cerumen is so impacted that the provider has to remove it with instrumentation and not by irrigation, then the provider should document the removal and the outcome. Then, there would be appropriate documentation for the 69210 for the cerumen impaction removal.

    Does this make sense and/or help?

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    Yes....makes sense. Thanks so much

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    You are welcome anytime.

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    So, I have another question now. If someone is referred to our clinic for an ear wash or even removal by instrumentation and the nurse does it.......if the documentation is there, would it be appropriate to charge a 99212 (minimal) and not the procedure? It is a nurse visit after all.

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    Woops! I meant to put 99211 as the E&M...not 99212 on that last entry.

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