subject: Expert Tips To Code Ear Diagnoses With Ease [print this page] During the winter season, patients' head colds lead to a variety of ear conditions. Here are some guidance to ensure you are coding right for all of the ear-associated diagnoses.
Verify documentation for E/M with 69210
Cerumen removal can present various coding challenges for your practice, particularly if the doctor carries out the service as a gateway to visualize the ear. Knowing when you can use 69210 is important to collecting for this service.
Do not consider Cerumen removal code when it 'falls out'
Before you go for 69210, you must see to it that you have documented a separately identifiable procedure.
While treating ear pain, match coding to final diagnosis
Sometimes medical coders can get tripped up when they read a presenting diagnosis on a chart - they will submit that ICD-9 code as the final diagnosis, even if the pediatrician finds a more definitive diagnosis during the visit. Most likely, the pediatrician should be providing the definitive diagnosis, preventing this problem.
For instance: A father brings his toddler to your office as he is suffering from ear pain and the pediatrician diagnoses earache with acute otitis media. The earache is thought of as inherent to the primary diagnosis. As such, you should go for only 382.00.
For outpatient encounters for diagnostic tests that have been interpreted by a doctor, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Don't code related signs and symptoms as additional diagnoses. However, if the doctor doesn't find any other condition besides ear pain, he should code the ear pain diagnosis code instead.
For more advice on ways to ensure you are coding right for all of the ear-associated diagnoses, sign up for a medical coding guide like Supercoder.
