simply irrigating the ear does not support the cerument removal code 69210.
Routine removal of cerumen is defined by CMS and CPT as the use of softening drops, cotton swabs, lavage and/or cerumen spoon and is not paid separately. It is considered incidental to the office visit and cannot be reimbursed on the same day as the E&M service. CPT also states specifically that:
...mere wax removal (eg, via lavage) does not warrant the reporting of CPT code 69210. Rather, that work would appropriately be captured by an evaluation and management code regardless of how it is removed." This is true regardless of whether removed by a nurse or otolaryngologist.
- CPT Assistant, July 2005
Billing and Payment Guidelines for 69210
69210 may be payable when the conditions defining impaction (see below) are met and the otolaryngologist or primary care physician removes the cerumen using an otoscope and wax curettes, forceps and/or suction.
The medical record should indicate which of the conditions outlined below were present, why the procedure was done, how difficult it was, method of removal, and extent of procedure. Statements on the difficulty, time, extra work required, etc will be considered as supporting information.
When billing cerumen removal and an E&M service, the documentation should support the complete performance of both codes. That is, if a patient's chief complaint is related to impacted cerumen, billing of the cerumen removal procedure may be the only appropriate code to bill. The E&M documentation must also be complete, reflecting the elements defined by CPT that are above and beyond the removal of the impacted cerumen.
You may request that Priority Health retrospectively review clinical documentation for reconsideration of payment for both an E&M service and removal of cerumen. See the Appeals section of this manual.
Conditions Defining Impaction
CPT has given its seal of approval to the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) definition of cerumen removal, which says that clinically, cerumen should be considered impacted only if any one or more of the following are present:
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.
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