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Ear pain diagnosis and impacted cerumen

Bernadette Posted Fri 19th of June, 2015 11:28:42 AM

Hi,

Patient comes to the office complaining of ear pain. The doctor examines her ear and sees there is wax impacted. The doctor curretted the ear and found there was no ear infection. Could we bill the ear pain diagnosis 388.70 with an E/M and modifier 25 along with the removal of impacted cerumen procedure 69210 (diagnosis code 380.4 would be used with 69210)? Please advise. Thanks!

SuperCoder Answered Mon 22nd of June, 2015 01:07:51 AM

Ideally E/M code should not be billed with CPT code69210 on same Date of service as patient came with ear pain and provider diagnosed with impacted wax and performed procedure for it. E/M service should be considered included in the procedure.

Bernadette Posted Tue 23rd of June, 2015 10:08:46 AM

Thank you...

If the doctor curetted the wax and found an ear infection, we could bill the E/M with modifier 25 and a diagnosis for the ear infection separately from the impacted ear wax diagnosis and removal procedure, correct?

SuperCoder Answered Wed 24th of June, 2015 00:11:52 AM

Correct.

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