Earwax removal coded as surgery during routine visit

My husband went to the Dr. to discuss bloodwork and get RX. While there he asked about having his ears cleaned, as he is a heavy wax producer. That extra procedure cost $50. The Dr. did not perform the procedure, it was done by the assistant.
He had no pain. Looks like the office coded it as surgery.
Is it worth calling the Dr. office to see if they could code it differently so that we are not on the hook for $50 ear cleaning?

re: Earwax removal coded as surgery during routine visit

69210 is rarely paid by any of the carriers... it's considered to be a part of the E&M service and therefore 'unbundled' by their claims edits... I would file it & start keeping a log of which carriers do & don't allow separate payment for this service...

re: Earwax removal coded as surgery during routine visit

There is no other way to code wax removal 69210. This is usually only paid in the office because it's such a minor procedure. The office visit is probably included in the wax removal because it doesn't sound significant.

re: Earwax removal coded as surgery during routine visit

Many times an o.v. and ear wax removal are appropriately coded together and paid separately.

It is often correct coding to report both procedures. Some payers incorrectly bundle one into the other.

re: Earwax removal coded as surgery during routine visit

However, the rules are that the clinician, not the assistant, must perform the service with instrumentation.

http://codapedia.com/article_355_69210-Cerumen-removal.cfm

re: Earwax removal coded as surgery during routine visit

[However, the rules are that the clinician, not the assistant, must perform the service with instrumentation.

http://codapedia.com/article_355_69210-Cerumen-removal.cfm]

Absolutely correct! There also must be a chief complaint documented of signs and symptoms or impacted cerumen.

re: Earwax removal coded as surgery during routine visit

This can be done by suction. If, it was just a cleaning and no impaction only an office visit should have been billed. Sounds to me like a $50 refund.

re: Earwax removal coded as surgery during routine visit

The code for removing impacted cerumen is a surgical CPT® code, 69210. Just like placing a splint is a surgical code but patients get confused and say "I didn't have surgery".

It is absolutely reasonable to bill both the office visit and cerumen removal (69210) if medical necessity exists for both services. So your husband went to discuss blood work and medications. That discussion was likely unrelated to the cerumen impaction, right? He didn't have an office visit for blood work and to discuss medications because of the wax in his ears. The wax in his ears was likely discovered at that visit - perhaps he complained about not being able to hear or perhaps the cerumen impaction was discovered upon exam at that visit. Or maybe he is seen every few months for cerumen removal. The point is the cerumen removal (69210) would be linked to a cerumen impaction diagnosis code (380.4). The E&M code would be linked to the diagnosis for the office visit (what did he have that required blood work and medications? Hypertension? Diabetes?).

CPT® 69210 requires use of magnification (eg, otoscope) and instrumentation (eg, suction, forceps). If the impacted cerumen was removed via lavage or irrigation, then it is not appropriate to report 69210 (the service would be included in any E&M code at that point).

Who can bill directly for cerumen removal (69210)? Any physician or other qualified health care provider. In the office setting, this service may also be billed "incident to" the physician if the physician asked his/her assistant to remove it. The physician diagnosed the cerumen impaction and set the plan for removal - the assistant carried out the plan at the physician's direction under the physician's supervision in the office setting so "incident to" rules apply. This is similar to the application of a split - the physician does not place the splint him/herself but the physician bills the application code because the assistant place it (again, assuming office setting and other "incident to" guidelines are followed).

Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Inc.
www.karenzupko.com

re: Earwax removal coded as surgery during routine visit

It is my understanding that to bill for the 69210 the service must be performed by the provider and instrumentation must be used. A ear wash/lavage would be included in the E&M for the visit. Earwax must be impacted.