Pediatric Coding Alert

Question: When reporting H61.21 or H61.22, do I still have to append a laterality modifier, even though laterality is built into the code?

Delaware Subscriber

Answer: The answer depends on whether the pediatrician removed the cerumen. If so, then even though H61.21 (Impacted cerumen, right ear) and H61.22 (… left ear) have laterality built in, you must also report the CPT^® code that most closely describes the actual procedure your provider performed and that corresponds with the laterality specified in the ICD-10 code. CPT^® includes two codes for removal of impacted cerumen:

• 69209 (Removal impacted cerumen using irrigation/ lavage, unilateral)
• 69210 (Removal impacted cerumen requiring instrumentation, unilateral)

This would mean you would append one of the following:

• LT (Left side)
• RT (Right side)
• 50 (Bilateral procedure)

If the provider did not remove the cerumen at that visit, then no modifier is necessary.

Remember: Some payers may want you to report bilateral impacted cerumen removal on two lines with modifier 50 on the second line. Others may prefer two lines with the RT modifier on one line and the LT modifier on the other. So, you will have to check payer guidelines before submitting your claim for this service.