An established patient is seen with complaints of bilateral ear pain for 3 days without fever. Physical examination of the right ear reveals impacted cerumen. The physician removes the impacted cerumen using an otoscope and curette; once the cerumen is removed, the physician finds and removes a foreign body. A foreign body is also found in the left ear and removed.
According to Current Procedural Terminology (CPT®) guidelines, the services should be reported as follows:
The evaluation and management (E/M) service would be reported using the office or outpatient established patient code 99212–99215 based on the performance and documentation of required key components (history, physical examination, medical decision-making). Most payers will require that modifier 25 (significant, separately identifiable E/M service) be appended to the E/M service.
Codes 69210 (removal of impacted cerumen) would be reported with modifier 59 (distinct procedural service) appended.
Code 69200 (removal of foreign body, external auditory...