by Scott Kraft
February 26th, 2016
2016 brings changes to how physician practices bill for the removal of impacted cerumen, including a new CPT code. The rules that apply to the two cerumen removal codes now available for use mean that auditors will need to scrutinize the documentation closely in order to ensure codes are being used correctly.
The traditional cerumen removal code has been 69210, which is for the removal of impacted cerumen using instrumentation, such as wax curettes. As auditors, when we have reviewed documentation for this service over the years, we're typically focused on making sure there is some documentation of the instrument that is used by the physician. When there was no documentation of any instrumentation, or if the cerumen was treated with irrigation or lavage, by rule 69210 would not be appropriate and the instruction has typically been that this type of impacted cerumen removal was considered part of the E/M service.
Where auditors haven't always been as sharply focused was on making sure that the documentation noted that the cerumen was impacted. Even though the code describes impacted cerumen, and even though a recently added CPT parenthetical states that removal of non-impacted cerumen is part of the E/M service, there is sometimes the belief that the required use of instrumentation almost implies the cerumen was impacted.
The addition of new code 69209, however, makes it more critical that physicians are trained to document that the cerumen is impacted. This new code carves out a way to bill a standalone code for the removal of impacted cerumen with irrigation or lavage. Prior to 2016, this was part of the E/M service, as noted above. However, again the cerumen must be impacted to use this code. It's far more typical that irrigation or lavage would be used for cerumen that is not impacted as a courtesy to the patient.
But the AMA's instructions for this code specifically state that the cerumen must be impacted. If it's not described as impacted in the documentation, there is no way to infer that it is impacted. By rule, this service if medically necessary - perhaps the patient cannot self-treat the cerumen - then it remains part of the E/M service. The same rule should apply to use of instrumentation and 69210. If the documentation does not specifically state that the cerumen was impacted, then the documentation really doesn't qualify to bill as 69210.