Weekly tip 69210 - instrumentation

In this forum thread feel free to post your comments and areas for discussion that you may have based on the weekly auditing and compliance tips from NAMAS.

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saj402
Posts: 7
Joined: Thu Jul 25, 2013 11:16 am

Fri Apr 10, 2015 10:34 am

I am struggling with this a little bit as CPT Assistant defines "instrumentation" as the use of an otoscope and other instruments. I find my providers do not document the use of an otoscope. Does the documentation of the procedure require they say the use an otoscope to get credit?

Oct 2013 CPT Assistant - "Another key factor in determining whether code 69210 should be reported is what instruments are utilized to remove the impacted ear wax. In this context, instrumentation is defined as the use of an otoscope and other instruments such as wax curettes and wire loops, or an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angle forceps)."

Thank you!
maryanne
Posts: 11
Joined: Fri Mar 20, 2015 10:49 am

Mon Apr 13, 2015 1:03 pm

I may be really off base here, but I do not believe that they would have to document the use of the otoscope. To me, it would be like saying that the provider had to document that they listened to the heart with a stethoscope. I think that it would be a given that they used a stethoscope, or an otoscope. I hope this helps, and if anyone has any documentation to the contrary, I sure would appreciate it! Have a good day! :)
Shannon DeConda
Global Moderator
Posts: 53
Joined: Thu Apr 12, 2012 2:53 pm
Location: Melbourne, FL
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Thu Apr 16, 2015 9:09 am

Yes- Maryann I would agree with your comments. Saj402 remember that providers are allowed implied concepts in the documentation and based on what they document in the exam it should verify these points.
Thank you,
Shannon O. DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN
Founder & President of NAMAS

Disclaimer: NAMAS cannot be held liable for any advice given that could have had a variable answer based on additional information.
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