Techniques of Cerumen removal and its codes

Ear wax, also called cerumen is a naturally extruded product of the external auditory canal to protect the human ears. It has both lubricating and antibacterial properties and is usually asymptomatic in nature. However if untreated, its build-up or accumulation can lead to hearing loss, irritation, otalgia, dizziness and other problems which requires medical attention immediately.

When treatment is appropriate, there are three methods to extract the impacted cerumen as below:

  1. Cerumenolytic agents
  2. Irrigation/lavage
  3. Instrumentation/manual

Before we look up the CPT codes for the above techniques, let’s know about these techniques for a better understanding.

Cerumenolytic agents: These are liquid solutions of either water based or oil based solutions that aid in softening or dissolving the ear wax. Typical ingredients found in water-based cerumenolytics include hydrogen peroxide, acetic acid, docusate sodium, and sodium bicarbonate. Common ingredients in oil-based cerumenolytics include peanut, olive, and almond oil. The most commonly prescribed cerumenolytic agent is carbamide peroxide.

Irrigation/lavage: This is a safer and effective method to remove the unwanted cerumen. Several irrigation methods are being used in the clinical setting and the most commonly used method would be the warm water or a 50/50 mix of water and hydrogen peroxide inserted into a syringe and discharged into the ear canal.

Manual Method: This method often requires specialized instrumentation to remove the impacted cerumen from the patient’s ears. The removal device involves a metal or plastic spoon, curettes, hooks, delicate forceps and suction.

Based on the above techniques that are involved in the process of cerumen removal, you have two CPT codes for use as below:

69209: Removal impacted cerumen using irrigation/lavage, unilateral

69210: Removal impacted cerumen requiring instrumentation, unilateral

Reporting 69209:

CPT 69209 is used to report for the removal of impacted cerumen using irrigation/lavage. It typically employs the use of saline solution to soften the impacted cerumen with or without cerumenolytics that may be administered at the time of procedure.

The important fact is that payers will not cover simple, non-impacted cerumen removal. This work is included in the E/M services and should not be reported separately with E/M services when performed. Only if impacted cerumen is removed by irrigation or lavage, you can use CPT 69209.

Reporting 69210

CPT 69210 is to be reported if the physician uses any instrumentation devices such as curettes, hooks, forceps and suction to remove the impacted cerumen from the patient’s ear. The key note is the type of instrument used and the document should clearly indicate the equipment required to provide the service.

Unilateral procedures:

The descriptors for codes 69209 and 69210 indicate that they are unilateral procedures. For bilateral impacted cerumen removal, you need to report these codes with modifier 50 – Bilateral procedure. However it is significant to note that Medicare does not allow the use of modifier 50 for impacted cerumen removal. To report to Medicare, you need to use these unilateral codes with no modifier whether performed unilaterally or bilaterally.

Report either 69209 or 69210, but not both:

Only one method of removal of impacted cerumen (either 69209 or 69210) may be reported when both are performed on the same day on the same ear. CPT® 69210 has higher relative value units than 69209 to capture the added complexity of the procedure.

Requirements for reporting impacted cerumen removal with an E/M on the same DOS:

Coders can report an E/M code with 69209 or 69210 if the following criteria are met:

  • The main reason for the patient’s visit was separate from the cerumen removal.
  • Otoscopic examination of the tympanic membrane is not possible due to the impaction.
  • Impacted cerumen removal requires the expertise of a physician or other qualified healthcare professional.
  • The procedure requires a significant amount of time and effort.

When all of the above criteria are clearly documented in the patient’s medical record, you can append modifier 25 to the E/M code indicating that it is a significant ad separately reportable E/M service by the same physician on the same day of the procedure.

Reporting G0268:

HCPCS Level II code G0268 should be billed only when the physician or other qualified healthcare practitioner removes impacted cerumen from a patient’s ear(s) on the same date as a contracted or employed audiologist performs audiologic function testing on the patient.

G0268: Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing

This code should not be used when the audiologist removes the cerumen as the removal of cerumen is considered to be part of the diagnostic testing and is not paid separately.

Resources:

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