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Internal Medicine Coding Alert

Reader Question:

Can 69209 Be Reported With 69210?

Question: Our internist performed removal of cerumen impaction of both the ears. He removed the cerumen through instrumentation in one ear and by irrigation in another ear. Can 69209 and 69210 be reported together as both the procedures were performed?

Nebraska Subscriber

Answer: If you look at the parenthetical note with 69209 (Removal impacted cerumen using irrigation/lavage, unilateral), it says that you cannot report the code with 69210 (Removal impacted cerumen requiring instrumentation, unilateral) for the same ear. Since your clinician performed the procedures in different ears, you can report both the procedures separately.

However, if you look at Correct Coding Initiative (CCI) edits, you will see that the two codes are bundled together with the modifier indicator ‘1.’ You can overcome the edit bundle by appending a suitable modifier such as 59 (Distinct procedural service) to 69209. However, you have to be able to support this modifier with appropriate documentation.