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Cerumen Removal

  1. Question Cerumen Removal
    Medical Coding Books
    Patient came in for ear pain and ear infection.
    Dr removed cerumen from ears druing this visit.

    Can I charge for office visit and cerumen removal [69210]?
    If not, when can this be charged?

    Thanks,

    CW

  2. #2
    Location
    Columbia, MO
    Posts
    12,526
    Default
    It really depends on the documentation and exactly what was done. If the ear was irrigated, then no, if the cerumen was removed to convenience the physician to be able to get a better look then no.
    You may code 69210 when there is a procedure note, that specifies the use of a scoop or currette by the physician and that this was performed to benefit the patient, example to give relief from pain.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Location
    Ellenville, New York
    Posts
    1,176
    Default CPT Assistant
    If you have access to the CPT Assistant, there was an excellent article on this topic in the July 2005 edition on the requirements for using 69210. Because of copyright laws, I can't cut and paste the article here, and this publication requires a subscription, so no link to post. But if your practice or facility has CPT Assistant, check out that article. I use it many time to our physicians for education on this procedure, as I too see it used often for simple removal or irrigation.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

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