Pediatric Coding Alert

These tips tell you when to use 69210. You can rest assured that claims for 69210 (Removal impacted cerumen [separate procedure], one or both ears) will hold up on chart audit provided you check off these items. 1. Check If Wax Meets Impaction Criteria You can only report 69210 with a diagnosis of impacted cerumen (380.4). Removing wax that is not impacted does not justify 69210. Instead, capture this work with an E/M code (99201-99215, Office or Other Outpatient Services) -- no matter how the provider removes the wax. To determine if documentation supports 384.0, use the definition from the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), which is also published in CPT Assistant July 2005. Consider cerumen clinically "impacted" if any one or more of the following are present: • Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle [...]