Myringotomy Includes Cerumen Removal
When reporting myringotomy (incision of eardrum) procedures (e.g., 69420 Myringotomy including aspiration and/or eustachian tube inflation and 69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia, do not separately report cerumen (earwax) removal for the same ear, using either 69210 Removal impacted cerumen requiring instrumentation, unilateral or an E/M code.
CMS’ National Correct Coding Initiative (NCCI) bundles cerumen removal into myringotomy codes 69420 and 69421. In addition, Chapter I of the “General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services,” states, “Since a myringotomy requires access to the tympanic membrane through the external auditory canal, removal of impacted cerumen from the external auditory canal is not separately reportable.”
If a physician or qualified practitioner must use instrumentation to remove, from a different ear, cerumen that has become impacted, you may separately report 69210 and append an appropriate modifier to indicate that the myringotomy and cerumen removal occurred at different locations. 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
Prior to Jan. 1, 2015 the most appropriate modifier to append when reporting 69210 for removal of cerumen from a different ear is modifier 59 Distinct procedural service. From Jan. 1, 2015 on, the more appropriate modifier choice for Medicare payers is modifier XS Separate Structure, which CMS created to describe services that are separate because they are performed on different anatomic organs, structures, or sites.