Question cerumen impaction

rleif1sun

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Monroe, NY
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patient seen for general adult medical examination and provider noticed ears impacted with cerumen. he removed with currette. is this an abnormal finding or is this normal?
 

nickelclaw

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Peru, IN
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I would say yes but also make sure you code the impacted wax and procedure:)
To me wax in ear is normal, however; impacted wax is not plus the need for procedure.

I know that this question to coding clinic doesn't pertain but note the meaning of abnormal finding from the answer:
Question:
A patient is seen for a well-child exam. He also has viral bronchitis, which was diagnosed during a previous visit, and is still under treatment. Would code Z00.121 or code Z00.129 be assigned in this case?

Answer:
Assign code Z00.129, Encounter for routine child health examination without abnormal findings, as the first-listed diagnosis. Assign also the appropriate code for viral bronchitis. An examination with abnormal findings refers to a condition/ diagnosis that is newly found, or a change in severity of a chronic condition, such as uncontrolled hypertension, or an acute exacerbation of chronic obstructive pulmonary disease, during a routine physical exam.
Code Z00.121 is not appropriate, since previously diagnosed conditions are not considered abnormal findings unless either exacerbated or uncontrolled during a current well child exam.

Cerumen removal, correct reporting
CPT Assistant, March 2016 Page: 10 Category: Frequently Asked Questions
Frequently Asked Questions: Surgery: Auditory System
Question:
How is removal of cerumen reported?
Answer:
For impacted cerumen removal that requires instrumentation (eg, cerumen loop/curette, forceps, suction, hook), report code 69210, Removal impacted cerumen requiring instrumentation, unilateral. For the removal of impacted cerumen using irrigation without instrumentation, report code 69209, Removal impacted cerumen using irrigation/lavage, unilateral. For the removal of cerumen that is not impacted, report the appropriate evaluation and management (E/M) service code (eg, 99201-99215, 99221-99223).
 
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