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cerumen removed by ED physician

Renee Posted Wed 11th of August, 2010 02:27:29 AM

Documentation states that the ED physician personally removed a small portion of impacted cerumen with a curet. However, the remainder could not be removed because it was too hard. The guideline states he should document how much time and the resources used to remove the cerumen. Should we code '69210' with mod -52 or not code it at all?

SuperCoder Answered Wed 11th of August, 2010 04:11:04 AM

I would code it with modifier 53 (Discontinued procedure). Modifier 52 is for when the physician or patient chooses to provide/have only part of a service. For instance, performing an inherently bilaterally service unilaterally. In contrast, if the physician reduces the service due to unexpected complications that place the patient at unacceptable risk, modifier 53 (Discontinued procedure) is appropriate. That is, the physician intends to provide the complete service but cannot do so due to unusual or extenuating circumstances.

In your example, the physician intended to complete a full impaced cerumen removal but due to unforseen circumstances could not complete it. Therefore, modifier 53 would be more applicable.

Jen Godreau, CPC, CPEDC
Content Director, Supercoder.com

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