Difficult Code: 69210
Cerumen removal reporting done right.
By G.J. Verhovshek, MA, CPC
Some CPT® codes cause more than their share of confusion, and judging from the feedback we receive from Healthcare Business Monthly readers, one such code is 69210 Removal impacted cerumen requiring instrumentation, unilateral. Here’s the information you need to clear the confusion.
E/M Covers Most Cerumen Removals
Most often, removal of excess cerumen by a physician or qualified non-physician practitioner (NPP) is inclusive of any evaluation and management (E/M) service provided. For example, the American Medical Association (AMA) provides us with the following three scenarios (as seen in CPT® Assistant; Coding Update, Auditory System; October 2013):
- The patient presents to the office for the removal of earwax by the nurse via irrigation or lavage.
- The patient presents to the office for the removal of earwax by a physician (any specialty) via irrigation or lavage.
- The patient presents to the office for earwax removal, which requires magnification provided by an otoscope or operating microscope, and instruments such as wax curettes, forceps, or suction by the primary care physician or otolaryngologist.
This latter situation occurs most commonly when impacted cerumen completely covers the eardrum and the patient has hearing loss.
Of these, the AMA writes, “Only the third scenario … would be reported with CPT® code 69210.”
Why? There are at least two reasons:
- The cerumen is “impacted” (and is documented, as such): This is a medical necessity issue. If the cerumen isn’t impacted, the service as described by 69210 is deemed not reasonable and necessary for removal.
The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) defines cerumen as impacted if one or more of the following conditions are present:
- Cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition;
- Extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, hearing loss, etc;
- Cerumen is associated with foul odor, infection, or dermatitis; or
- Obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician skills.
2. Instruments were used: The AMA added a parenthetical note to CPT® 2014 instructing, “For cerumen removal that is not impacted [see above] or does not require instrumentation, eg, by irrigation only, see E/M service code, which may include new or established patient office or other outpatient services …” AMA revised the CPT® descriptor for 69210 to specify, “requiring instrumentation.” Irrigation (ear lavage) methods are considered to be part of an E/M visit. Provider advocacy groups and payers, alike, observe these requirements.
REASON FOR VISIT: Woman comes in with bilateral blocked ears.
EXAM: Patient in no acute distress, afebrile, impacted wax both ears.
ASSESSMENT & PLAN: Bilateral cerumen occlusion irrigated by nursing.
CPT®: 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making..
ICD-9-CM: 380.4 Impacted cerumen
Some payers may stipulate a third requirement to report 69210: The necessity of “advanced practitioner skill” to remove the cerumen. Historically, many payers have required a physician to provide the service. Some payers continue to observe this restriction, while others may allow an NPP (such as nurse practitioner, physician assistant, or clinical nurse specialist) to perform and report 69210. Inquire with your individual payers to be certain of their requirements.
Distinguish Bilateral Procedures
CPT® identifies 69210 as a unilateral procedure. If the provider removes impacted cerumen from both the right and left ears, you may report a bilateral procedure. For many payers, a bilateral procedure may be reported using a single unit of 69210, with modifier 50 Bilateral procedure appended, as indicated in the CPT® 2014 codebook.
Note, however, that the 2014 Medicare National Physician Fee Schedule Relative Value File assigns 69210 a “2” bilateral indicator. This means that for Medicare payers, the relative value units assigned to 69210 “are already based on the procedure being performed as a bilateral procedure.” In contrast to CPT® instructions, the Centers for Medicare & Medicaid Services (CMS) allows only one unit of 69210 to be billed when furnished bilaterally.
In other words: Medicare won’t pay anything extra if you report cerumen removal bilaterally. Check with your individual payers to determine their policies.
Documentation Requirements for 69210
To ensure proper reporting of 69210, documentation in the medical record should ideally include:
- Location of impacted cerumen (left ear, right ear, or bilateral)
- Instrumentation and/or magnification used, including otoscope and/or operating microscope
- Method of removal (forceps, suction, curettes, etc.)
- Time and effort
- Patient instruction given, and outcome
REASON FOR VISIT: 59-year-old pleasant male presents today for blocked left ear due to ear wax.
EXAM: General: Well-developed, well-nourished, pleasant male in no apparent distress. Ears: The left ear has a massive cerumen impaction visible with an otoscope in the auditory canal.
PROCEDURE: The impacted cerumen is gently grasped with alligator forceps and gently removed. The patient tolerated this well. The tympanic membrane was pearly and mobile bilaterally.
ASSESSMENT & PLAN: Instructions for ear cleansing was given and the patient was instructed to return if symptoms reoccur.
Many Payers Bundle Visualization
Removal of impacted cerumen is often achieved with the use of visualization aids, such as the binocular microscope (92504 Binocular microscopy (separate diagnostic procedure)). Although the AAO-HNS recommends separately reporting 92504 with cerumen removal when using the binocular microscope, per CPT®, 92504 is a “separate procedure,” and most payers will bundle the visualization with 69210. For example, Blue Cross and Blue Shield of North Carolina’s (BCBS) Corporate Medical Policy for Removal of Impacted Cerumen states, “Visualization aids, such as, but not necessarily limited to, binocular microscopy, are considered to be included in the reimbursement for 69210.”
Same-day Removal May Depend on Payer
Do not report an E/M service on the same day as 69210 unless the E/M is a significant, separately identifiable service. For example, the BCBS Corporate Medical Policy, cited above, specifies, “When  is reported in addition to an E&M service, the medical record must clearly reflect the procedure was separate from the reason for the E&M encounter.” Per CMS, the following criteria must be met when reporting an E/M visit and cerumen removal on the same date of service:
- The initial reason for the patient’s visit was separate from the cerumen removal.
- Otoscopic examination of the tympanic membrane is not possible due to the impaction;
- Removal of the impacted cerumen requires the expertise of the physician or NPP and is personally performed by him or her;
- The procedure requires a significant amount of time and effort; and
- All of the above criteria are clearly documented in the patient’s medical record.
A separate E/M may be reported with the appropriate E/M service code, as supported by documentation, with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended. One possible scenario is given in the May 2003 CPT® Assistant:
A physician examines a new patient exhibiting symptoms of an upper-respiratory infection that has progressed to unilateral purulent nasal discharge and discomfort in the right maxillary teeth. The physician performs and documents a detailed history and detailed examination. The physician determines that the medical decision making is of low complexity and also documents this in the patient’s medical record. This new patient encounter is reported with E/M service code 99203 Office or other outpatient visit.
During the examination, the patient communicates to the physician that the hearing in his left ear is not as distinct as his right ear. Upon examination of the left ear, the physician notes a large amount of impacted cerumen. The physician proceeds to suction the impacted cerumen in the patient’s left ear.
To report this patient encounter, the physician appends Modifier ‘-25’ to code 99203, and separately reports code 69210 … to indicate that both a significant E/M service and a procedure were performed on a given day.
Audiologists Cannot Report Cerumen Removal
The National Correct Coding Initiative (NCCI) bundles 69210 to audiology testing codes with the assumption that clearing earwax/impacted cerumen is a precondition to the testing (see: Federal Register, December 31, 2002, pages 80011–80012). Check the NCCI edits before reporting 69210 in addition to diagnostic testing.
CMS created HCPCS Level II code G0268 Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing to allow physicians to report removal of impacted cerumen (in lieu of 69210) on the same date as a contracted or employed audiologist who performs audiologic function testing. Do not report G0268 when the audiologist removes the cerumen; the removal is considered to be part of the diagnostic testing and is not paid separately. Medicare may pay audiologists only for medically necessary diagnostic testing, not for services billed with 69210.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.