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69210 Removal Impacted Cerumen (partial)

T

Traci Watson

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4
Location
Northbridge, MA
What would be the correct coding for the following?

Scenario: Patient presents for removal of impacted cerumen. Impaction is confirmed on exam. Wax removal was attempted but unable to be fully completed to to patients discomfort.
 
I would use modifier -53 if the intent was to complete the 69210 (the provider did not plan to perform a reduced procedure) and the procedure was discontinued due to threatening the well-being of the patient (pain).
 
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