You walk into the exam room and find a 4-year-old who is crying, and you haven’t even touched the child yet! Mom tells you that her child has been crying for 2 days now, stating that both ears “kill.” There is no history of fever and mom recalls seeing a slightly yellow nasal discharge the last several days.
There is no past history of ear infections. Upon examination of the ears, all you can see is impacted cerumen. There is no cervical adenopathy and there is minimal post-nasal drip.
Via instrumentation you remove the cerumen from both ears and voilà - no more pain.
How do you want to code this?
b. 99212 and 69210
d. none of the above
None of the above is the correct answer because you removed cerumen from both ears You cannot use the 99213 because your documentation does not support that code.
I would code this as 99212 and 69210, 69210-50. The 69210 is removal of cerumen and the 50 modiifer indicates that this was a bilateral procedure. It is only recently that we can bill for removal of cerumen from both ears.
Remember, though, that the removal must be through instrumentation and not lavage.
— Richard Lander, MD, is a pediatrician in private practice in northern New Jersey and clinical assistant professor of pediatrics at the University of Medicine and Dentistry of New Jersey in Newark, N.J. He is immediate past chair of the AAP Section on Administration and Practice Management and a member of the Infectious Diseases in Children Editorial Board.
Disclosure: Lander is co-owner of both the National Discount Vaccine Alliance, and Resources in Physician Management Services. He also is a speaker for Merck and Sanofi-Pasteur.