Cerumen Removal Coding Depends on Impaction, Method
Factor in the components of the common family practice procedure.
Cerumen (ear wax) can build up in the ear canal, which may lead to symptoms of discomfort, dizziness, and impaired hearing for which patients seek medical care. In fact, the American Family Physician website tells us that cerumen removal is the most common ear, nose, and throat (ENT) procedure performed in primary care.
Coding for cerumen removal depends on two factors:
- Whether the cerumen is impacted; and
- If the cerumen is impacted, the method used to remove it.
Not Impacted = E/M Service
CPT® guidelines tell us, “For cerumen removal that is not impacted, see E/M service code …” such as new or established office patient (99201-99215), subsequent hospital care (99231-99233), etc. In other words: If the earwax isn’t impacted, removal is included in the documented evaluation and management (E/M) service reported and may not be separately billed.
Per the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), cerumen is 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.
The AMA’s CPT® Changes 2016: An Insider’s View confirms, “Impacted cerumen is typically extremely hard and dry and accompanied by pain and itching. Impacted cerumen obstructing the external auditory canal and tympanic membrane can lead to hearing loss.”
Method Determines Coding for Impacted Removal
If earwax is impacted, it may be removed by one of two general methods: lavage (irrigation) or instrumentation. For removal by lavage, the correct code is 69209 Removal impacted cerumen using irrigation/lavage, unilateral. For removal using instrumentation (e.g., forceps, curette, etc.), turn instead to 69210 Removal impacted cerumen requiring instrumentation, unilateral.
CPT® Changes 2016: An Insider’s View specifies:
Code 69210 only captures the direct method of earwax removal utilizing curettes, hooks, forceps, and suction. Another less invasive method uses a continuous low pressure flow of liquid (eg, saline water) to gently loosen impacted cerumen and flush it out … Code 69209 enables the irrigation or lavage method of impacted cerumen removal to be separately reported…
You may report a single unit of either 69209 or 69210 (never both), per ear treated. As an example of proper reporting for 69209, CPT® Changes 2016: An Insider’s View provides the following:
A 7-year-old male child comes in for his well-child exam. He fails his hearing screen in the left ear. On examination, the physician is unable to see the tympanic membrane due to cerumen impaction. An order is placed for the nurse to irrigate the ear.
Both 69209 and 69210 are unilateral procedures. For removal of impacted earwax from both ears, append modifier 50 Bilateral procedure to the appropriate code. In the example above of the 7-year-old child, if irrigation occurred in both ears, appropriate coding is 69209-50.
When billing Medicare payers, different bilateral rules apply for 69210. The 2016 Medicare National Physician Fee Schedule Relative Value File assigns 69210 a “2” bilateral indicator. This means, 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 us to report only one unit of 69210 for a bilateral procedure. CMS does allow us to bill a bilateral procedure for cerumen removal by lavage using 69209-50.
Finally, note that some payers may stipulate “advanced practitioner skill” is necessary to report removal of impacted earwax (i.e., payers may require that a physician provide 69209, 69210). Query your individual payers to be certain of their requirements.
John Verhovshek, MA, CPC, is managing editor at AAPC and a member of the Hendersonville-Asheville, N.C., local chapter.