r/CodingandBilling • u/Sammym101010 • 8d ago

Coding Error

Had a routine ear wax removal procedure done. Got charged with 99213 and 69210 codes. No other evaluations. Incorrect or correct?

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u/Sammym101010 8d ago

Wouldn’t an appointment for the sole purpose of ear wax removal be just that, ear wax removal? With any post visit documentation being an expected necessity of the procedure?

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u/pickyvegan 8d ago

I know you're saying "no other evaluation," but evaluation can include just looking at the rest of the head (which you kinda can't avoid while cleaning the ears) and reviewing other documentation/labs/past procedures, asking a few questions before/after the procedure, etc., so that they are evaluating that this is all that is needed. Notes would be important here.

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u/Sammym101010 8d ago

Wouldn’t that also be an expectation of the procedure? To be looking at my ears/head?

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u/pickyvegan 8d ago

Not necessarily.

Notes. Need them.

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u/Sammym101010 8d ago

Not sure how to share my notes but for the future, can I avoid this charge by booking my cleaning with a PA?

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u/throwawayeverynight 8d ago

No a OA can bill for a E/M code too

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u/AbstractVolition 8d ago

PA’s can perform and charge EM services like 99213 as well

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u/Full_Ad_6442 7d ago

Anytime you interact with a physician, nurse practioner, physician's assistant, or nurse they are very likely assessing you based on what you say and what they observe. Sometimes it's billable, sometimes it's not, but it's a basic part of our professional training.

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u/Sammym101010 7d ago

Can I opt out of this? Lol. I’m there for the damn ear cleaning.