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Removal of impacted cerumen

  1. #1
    Default Removal of impacted cerumen
    Medical Coding Books
    I have a patient who came in on 10/9/08, our MA did a removal of cerumen. She called the next day complaining about pain, she came back on the 20th. The wax was not completely removed so our physician did a repeat to remove the wax. Am I correct in saying that we can charge for the removal on both visits? And do I use a modifier 76 on the second removal even though the MA did the first removal, we bill everything with the physician as the supervisor.

    Thank you
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  2. Default
    If the MA does the removal you cannot bill for it. You can only bill when the doctor removes the wax with a currette, lighted spoon or uses a microscope.

  3. #3
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    lisamilo is absolutely correct. The procedure MUST be done by the doctor, PA or NP.
    Lisa Bledsoe, CPC, CPMA

  4. #4
    Location
    North Carolina
    Posts
    3,126
    Default
    Some time ago, Mary posted an excellent explanation for this scenerio.

    http://www.aapc.com/MemberArea/forum...ad.php?p=24392

  5. Default
    Very true, 69210 may only be billed when performed by the Physician or NPP. I tried to updload a couple of documents in relation to this but the file limit for aapc is too small. I've got a coding alert article and a clarification from BCBSM. If you'd like those, give your email address and I'll send them on.

  6. Default
    Quote Originally Posted by Lisa Curtis View Post
    lisamilo is absolutely correct. The procedure MUST be done by the doctor, PA or NP.
    I agree. Absolutely correct!
    ~Amy, CPC, CPMA, CEMC~
    Auditor/Consultant

  7. #7
    Default
    Ok, so even though the nurse did it under the supervision of the physician with the utensils, we can't bill the 69210?
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  8. #8
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Nope - the doctor/PA/NP must do it.
    Lisa Bledsoe, CPC, CPMA

  9. #9
    Default
    Thank you all so much, I understand although I'm completely confused at the same time . Can you look at the physician note below and tell me if this is justified? Thanks again ....

    Electronically signed by provider on 10/21/2008 04:45:38 PM
    SUBJECTIVE:

    CC:
    Ms. Patient is a 81-year-old female. She presents with earache.

    HPI:
    Mrs Patient presents with complaint of both ears hurting for a couple of days. She says that she has been dealing with watery eyes and runny nose that is so bad that it runs water when she bends over. Now both of her ears hurt. She denies fever or chills, cough or sore throat.

    ROS:
    CONSTITUTIONAL: Negative for chills, fatigue, fever and night sweats.
    EYES: Negative for blurred vision and eye pain.
    E/N/T: See HPI
    CARDIOVASCULAR: Positive for claudication, dizziness, pedal edema ( moderate ) and varicosities. Negative for chest pain, palpitations or paroxysmal nocturnal dyspnea.
    RESPIRATORY: Positive for frequent wheezing. Negative for recent cough or dyspnea.
    GASTROINTESTINAL: Positive for constipation and heartburn. Negative for abdominal pain, abdominal bloating, diarrhea, nausea or vomiting.
    MUSCULOSKELETAL: Positive for arthralgias, back pain and myalgias.
    INTEGUMENTARY/BREAST: Negative for atypical moles, dry skin, pruritis, rashes, breast masses, and nipple discharge.
    NEUROLOGICAL: Positive for ataxia, dizziness, memory loss, tremor, vertigo and weakness.
    HEMATOLOGIC/LYMPHATIC: Positive for easy bruising.
    PSYCHIATRIC: Negative for anxiety, depression, and sleep disturbances.

    Past Medical History / Family History / Social History:

    Past Medical History:

    Coronary Artery Disease
    Hypertension
    Hypothyroidism

    Surgical History:

    Positive for
    Hysterectomy;
    Positive for
    Joint Replacement:
    Knee Replacement: Summer 2007 right, left previously; ; ;
    Positive for Pacemaker placed July 2007;

    Family History:

    Positive for Myocardial Infarction ( father; brother -- her father and both brothers all died at age 56 from heart attacks ).

    Current Problems:
    CHF
    Degenerative arthritis of knee
    Essential hypertension, benign
    Fatigue
    Hypothyroidism
    Morbid obesity
    Obstructive sleep apnea (adult) (pediatric)
    Varicose veins of lower extremities, with Pain

    Immunizations:
    None

    Allergies:
    Radiographic Dyes/Iodine:

    Current Medications:
    Synthroid 0.075mg Tablet Take 1 tablet(s) by mouth daily
    Prozac 10mg Capsules Take 1 capsule(s) by mouth daily
    Spironolactone 50mg Tablet Take 1 tablet(s) by mouth bid
    Furosemide 20mg Tablets Take 1 tablet(s) by mouth daily
    Klor-Con 10 Tablets, Extended Release Take 1 tablet(s) by mouth daily
    Lasix 40mg Tablet Take 1 tablet(s) by mouth bid
    Micro-K 8mEq Capsules, Extended Release Take 1 cap by mouth daily
    Prinivil 5mg Tablet Take 1 tablet(s) by mouth daily
    Toprol XL 100mg Tablets, Extended Release Take 1 tablet(s) by mouth daily
    Oxybutynin Chloride 5mg Tablet Take 1 tablet(s) by mouth bid
    one day mult vitamin daily

    OBJECTIVE:

    Vitals:

    Current: 10/21/2008 3:51:35 PM
    Ht: 64 inches; Wt: 245 lbs; BMI: 42.05
    T: 98.2 F (oral); BP: 134/72 mm Hg (left arm, sitting); P: 61 bpm (left arm (BP Cuff), sitting); R: 20 bpm

    Exams:

    GENERAL: morbidly obese; well groomed; no apparent distress
    EYES: pale; EOMI;
    E/N/T: normal external ears and nose;; Ears: both TMs are obscured by cerumen; Hearing Screen: Able to hear fingers rubbed together with both ears; Nasal Septum/Mucosa: partially obscured by clear drainage; Oropharynx: normal mucosa; Post nasal drip; After irrigation the left TM is normal, the right canal is red and the TM is slightly bulging and red around the edges. Patient states it is painful.
    NECK: Neck is supple with full range of motion;
    RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs;
    CARDIOVASCULAR: normal rate; regular rhythm; normal S1 and S2 heartsounds with no S3 or S4; a systolic murmur is noted: it is grade 3/6; ;
    LYMPHATIC: no enlargement of cervical nodes;
    MUSCULOSKELETAL: gait: ambulatory with walker;
    PSYCHIATRIC: mental status: alert and oriented x 3; appropriate affect and demeanor; good insight and judgement;

    Procedures:
    Cerumen impaction

    Procedure: Cerumen impaction is noted in both ears. The degree of wax accumulation is moderate in the left ear and right ear. With moderate dificulty, using a syringe irrigation, the wax is removed. Removed from ear was hard balls of wax. The patient tolerated the procedure well.
    There were no complications.


    ASSESSMENT:

    388.71 Otalgia, otogenic origin
    381.01 Acute serous otitis media
    380.4 Cerumen impaction
    477.9 Allergic rhinitis, NOS

    PLAN:

    Otalgia, otogenic origin

    FOLLOW-UP: Advised to call if there is no improvement 2 days.

    Prescriptions:
    Tramadol 50mg Tablet one po q 6 hrs, prn for pain #12 (Twelve) tablet(s) Refills: 0

    Acute serous otitis media

    Prescriptions:
    Azithromycin 250mg Tablet Take 2 tablet(s) by mouth on day 1 then 1 tablet every day for the next 4 days. #6 (Six) tablet(s) Refills: 0
    Floxin Otic 0.3% Otic Solution Instill 5 drop(s) in affected ear(s) daily for 7 days #1 (One) 5 ml bottle Refills: 0

    Cerumen impaction

    Orders:
    Removal impacted cerumen, one or both ears
    A4550 Surgical trays (x1)

    Allergic rhinitis, NOS

    IMMUNIZATIONS given today: Immunization admin., each additional > 3 y/o and Influenza.

    Prescriptions:
    Samples: Nasonex 50mcg/actuation Nasal Spray 2 spray(s) in each nostril daily quantity: 1 lot #: 8 MAA 33

    Orders:
    Immunization administration; each additional vaccine/toxoid > 8 y/o
    Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramus


    Patient Recommendations:

    For Otalgia, otogenic origin:
    Follow-up by phone if no improvement in 2 days.


    CHARGE CAPTURE:

    Primary Diagnosis:
    388.71 Otalgia, otogenic origin

    Orders:
    99214-25 Office/outpatient visit; established patient, level 4

    381.01 Acute serous otitis media

    380.4 Cerumen impaction

    Orders:
    69210 Removal impacted cerumen, one or both ears
    A4550 Surgical trays (x1)

    477.9 Allergic rhinitis, NOS

    Orders:
    90472 Immunization administration; each additional vaccine/toxoid > 8 y/o
    90658 Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramus
    Sincerely,

    Kristie Stokes, CPC, CPMA, CCS, CMDP, ICDCT-CM

    AAPCCA Board of Directors 2014-2017
    Region 1 - Northeast
    Maine, New Hampshire, Vermont, Massachusetts, Connecticut, Rhode Island, New York

    Today, give a stranger one of your smiles. It might be the only sunshine they see all day.

  10. Default
    Kristie,

    2008 Coders Desk Reference cites 69210 as, "Under direct visualization, the physician removes cerumen (ear wax) using suction, a cerumen spoon or delicate forceps. If no infection is present, the ear canal may be irrigated."

    The physician or non-physician provider, aka Nurse Practioner, Physician Assistant, Certified Nurse Midwife, must be the one to perform the removal. Irrigation is the last step of the procedure as long as there is no infection.

    Unless I missed something while reading, another concern is the documentation does not tell that the M.A. did the cerumen impaction removal. Whoever is doing, aka 'providing', the service must be the one to document and sign off for their portion. It might be in your practices best interest to advise the EMR developer of this concern.

    If the physician him/herself does not perform cerumen impaction removal using instrumentation, it cannot be billed. If you'd like me to email the attachments that won't post here, I'd be glad to do so.

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