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Internal Medicine Coding Alert

You Be the Coder:
Same Day Injection and Cerumen Removal Are Bundled

Question: Our internal medicine specialist recently performed cerumen removal and provided an injection to the patient. Can I report both the cerumen removal and the injection service separately? Both the services were performed by our physician only. Also, let me know if a separate E/M code can be reported for the visit?

Nebraska Subscriber

Answer: You will most likely report the injection administration with 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular). You report the cerumen removal with 69210 (Removal impacted cerumen requiring instrumentation, unilateral). Note that 69210 covers removal of the impacted cerumen from one ear. If your physician performed cerumen removal from both the ears, you should report 69210 with modifier 50 (Bilateral procedure) appended.
According to Correct Coding Initiative (CCI) edits, the injection code 96372 is bundled into the code for cerumen removal (69210). However, the modifier indicator for this code bundle is ‘1,’ which means you can separately report the codes by using a suitable modifier. Since the injection code is the column 2 code in the edit bundle with 69210, you append the modifier to 96372. The modifier that you will use with 96372 is 59 (Distinct procedural service).
You should not report an E/M service code as a routine practice with either 96372 or 69210. You are only allowed to report an E/M service code for the same encounter if the E/M service is separately identifiable and significant. Again, an E/M code also faces edit bundles according to CCI. The modifier indicators to these bundles are also ‘1,’ which means you can unbundle the codes and report the E/M code separately.
Since the E/M is the column 2 code in the edit bundles with both 96372 and 69210, you will have to append the modifier to the E/M code. The modifier that you will use with the E/M code to enable separate reimbursement is 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).
Don’t forget: The CPT® code 96372 is only for the administration of the injection. Don’t forget to report the appropriate J code for the supply of the drug that is being administered. Also, note that 69210 can be reported only if your physician removes impacted cerumen from the ear using instrumentation. You cannot report this code if your physician only performs irrigation of the ear.