Posted on 10. Sep, 2009 by in Hot Coding Topics
If your PCP is billing 69210 (Removal impacted cerumen [separate procedure], one or both ears), you can bet the auditors will be checking your documentation. If you follow these 3 tips, you can be sure you’re using the code correctly.
1. Check If Wax Is Impacted
The first thing that you need to do is to fully understand the definition of impacted cerumen (384.0). “Remember that 69210 is actually a surgical procedure,” urges Kris Cuddy, CPC, CIMC, independent consultant in DeWitt, Minn.
The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) says that if any one or more of the following are present, cerumen is considered clinically “impacted”:
• Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.
• Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.
• Inflammatory considerations: Associated with foul odor, infection, or dermatitis.
• Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.
2. Absent Instrumentation? Use E/M, Not 69210
“The ear lavage, which is sometimes confused with cerumen removal, is actually part of an E/M visit and able to be performed by a nurse,” explains Karen K. Byrne, RN, BS, CPC, CEMC, coding analyst, Carolina Health Specialists, Myrtle Beach, S.C. “There is no specific code for lavage including water piks.” Removing wax that is not impacted also does not justify 69210. This work is captured by an E/M code — no matter how it is removed.
According to the AAOHNS, the following scenarios do not justify the use of 69210:
Patient scenario #1: The patient presents to the office for...
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