Wiki Technique for cerumen removal matter?

[Orthocoderpgu]

We just had a friendly audit (we hired the auditors) and a patient came in for an office visit and had impacted cerumen removed. The auditor said that the cerumen removal was not billable since the way the cerumen was removed was not documented. Does the specific way it's removed need to be documented for this to be billable ??

 

[RebeccaWoodward*]

Excerpt from CPT Assistant.....

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.