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Internal Medicine Coding Alert

You Be the Coder:

Reporting E/M with Cerumen Removal

Question: If your physician performs removal of cerumen, can an E/M code be reported for the evaluation that was performed? If so, should a modifier be appended to the E/M or the cerumen removal code?

Maryland Subscriber

Answer: You report one of the two below mentioned codes when your clinician performs cerumen removal depending on whether he used instruments or performed a lavage:

  • 69209 (Removal impacted cerumen using irrigation/lavage, unilateral)
  • 69210 (Removal impacted cerumen requiring instrumentation, unilateral).

As with most of the procedural codes, you should not routinely report an E/M code for the pre-procedural evaluation that your clinician performed. However, if your clinician performed an evaluation of the patient that was distinct and separately identifiable from the cerumen removal procedure performed, you can report an E/M code for this evaluation.

However, you will need to append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code that you are reporting in order to let the payer know that the E/M code is significant and separately identifiable from the cerumen removal.