From CPT Assistant 7/2005. I do not agree with the last line of the second to last paragraph, however, because both 92504, binocular microscope and removal of impacted cerumen are both separate procedures so I cannot see the appropriateness of coding both together, when they are both used on the same site, same ear.
Surgery: Eye and Ocular Adnexa––Coding Clarification
Question:The May 2004 CPT Assistant Coding Communication titled “Eye and Ocular Adnexa” provides a diagnosis and conditions list (page 11) for which amniotic membrane and limbal stem cell transplants are performed to treat. Is this a comprehensive list or are these provided as examples only?
AMA Comment: It is important to note that the list included in that particular Coding Communication is provided as an example only. It does not represent a comprehensive diagnosis and conditions list for which amniotic membrane and limbal stem cell transplants are performed to treat.
Surgery: Auditory System
In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), we present the following discussion which provides some typical coding scenarios with regard to the appropriate use and application of CPT codes related to ear wax removal:
1. The patient presents to the office for the removal of “ear wax” by the nurse via irrigation or lavage.
2. The patient presents to the office for the removal of “ear wax” by the primary care physician via irrigation or lavage.
3. The patient presents to the office for “ear wax” removal as the presenting complaint. This is described as impacted cerumen because it completely covers the eardrum and the patient has hearing loss. The impacted cerumen is removed by the primary care physician or otolaryngologist with magnification provided by an otoscope or operating microscope and instruments such as wax curettes, forceps, and suction.
Question:Are these procedures appropriately reported with CPT code 69210, Removal impacted cerumen (separate procedure), one or both ears?
AMA Comment: A major element in determining whether code 69210 should be reported is understanding the definition of impacted cerumen. By definition of the AAO-HNS, “If any one or more of the following are pre-sent, cerumen should be considered ‘impacted' clinically:
* Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.
* Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.
* Inflammatory considerations: Associated with foul odor, infection, or dermatitis.
* Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.”
Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting of CPT code 69210. Rather, that work would appropriately be captured by an evaluation and management (E/M) code regardless of how it is removed. If, however, the wax is truly impacted, then its removal should be reported with 69210 if performed by a physician using at minimum an otoscope and instruments such as wax curettes or, in the case of many otolaryngologists, with an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angles). Accompanying documentation should indicate the time, effort, and equipment required to provide the service. Add-on code 69990, Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure), should not be reported if the operating microscope is used for cerumen removal. In this later instance, however, code 92504, Binocular microscopy (separate diagnostic procedure), may be reported.
Therefore, based on this information, scenarios 1 and 2 would not be reported with code 69210. These scenarios would be captured by the appropriate E/M code. Scenario 3, however, should be reported with code 69210 because both criteria were met; the patient had cerumen impaction and the removal required physician work using at least an otoscope and instrumentation rather than simple lavage.
