tci E/M Coding Alert - 2020 Issue Q2

Reader Question: Reach for E/M When Provider Removes Unimpacted Cerumen

Question: Our pediatrician removed cerumen from a patient’s left and right ears. The cerumen was not impacted. Can I use 69209 or 69210 for the removal with modifier 52 to show the procedure was changed because the cerumen was not impacted and modifier 50 to show the procedure was performed on both ears? Also, should I use H61.2- for the diagnosis? New Hampshire Subscriber Answer: As the patient’s cerumen was not impacted, you cannot use 69209 (Removal impacted cerumen using irrigation/ lavage, unilateral) or 69210 (Removal impacted cerumen requiring instrumentation, unilateral). The codes are exclusively used...

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