When the nurse removes impacted cerumen, should modifier 25 be appended to the evaluation and management (E/M) service or to code 69210 (removal of impacted cerumen)?

Current Procedural Terminology code 69210 may be reported when a patient has cerumen impaction and the removal requires physician work using, at a minimum, an otoscope and instruments (eg, wax curettes). Medical record documentation must support that the cerumen was impacted and removed by the physician. The procedure note should include a description of what equipment and method were used for the removal (eg, type of visualization and instruments used). Removal of impacted cerumen by irrigation or lavage, whether performed by the nurse or physician, cannot be reported with code 69210 and is considered part of the E/M service.

Modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of a procedure or other service) should be appended to...

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