# Ear Lavage coding



## jaldrich

I'm curious what others think about coding 69210 for ear lavage when the doctor documents that the wax was impacted, but the ear only needed to be lavaged (no other instruments were used)?  I'm curious whether a syringe should be considered instrumentation (as described in the CPT Assistant)?  
thank you


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## Candice_Fenildo

Removal of impacted wax typically requires the use of an otoscope as well as other instruments including wax curettes, forceps, right angles and suction.
I work for an ENT and typically we get the patients that come in from their PCP after a Lavage. 

I am almost certain that lavage would be billed as part of the E/M. 
Curious to see other responses


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## beckyz

*ear lavage*

I agree that the use of an otoscope and/or forceps or other instrument needs to be used in order to bill for the removal.   We typically consider the lavage part of the E/M service.

Becky Zellmer, CPC, MBS, CBCS
Provider Education
Prevea Health


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## mrssnail

This would not be separately billable and would be included in the E/M service provided. Code 69210 should not be used to report an irrigation or lavage done by either a nurse or a physician. The 69210 should only be used when, 1. the patient has a cerumen impaction (380.4) and 2. the removal requires physician work using at least an otoscope and instrumentation, rather than simple lavage. Instrumentation can be wax curettes, forceps and suction. Documentation: you should have a separate entry from the physician to support the procedure. Accompanying documentation should indicate the time, effort, and equipment required to provide the service. This information was obtained via The Coding Institute November, 2005 Internal Medicine Coding Alert. Hope this helps. I have the article if this would be helpful, just let me know.


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## b.cobuzzi

I agree with the others and CPC Assistant from 7/2005 also supports this position.  An ear wash squeegy is not an instrument.


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## bsuse

mrssnail said:


> This would not be separately billable and would be included in the E/M service provided. Code 69210 should not be used to report an irrigation or lavage done by either a nurse or a physician. The 69210 should only be used when, 1. the patient has a cerumen impaction (380.4) and 2. the removal requires physician work using at least an otoscope and instrumentation, rather than simple lavage. Instrumentation can be wax curettes, forceps and suction. Documentation: you should have a separate entry from the physician to support the procedure. Accompanying documentation should indicate the time, effort, and equipment required to provide the service. This information was obtained via The Coding Institute November, 2005 Internal Medicine Coding Alert. Hope this helps. I have the article if this would be helpful, just let me know.


could you please send me a copy of the article? our nurses our doing our ear flushes with syringes only,and most of the docs do not get involved. i saw int the coding edge this month that the provider is the one that needs to do the work, but i need something solid in writing to bring to my manager. any light you can shed on this for me would be appreciated.
Barbara.Suse@vrh.org thanks!


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## Barbara A. Love

I recently did an audit of a group of my providers who submitted 200 encounters which included the CPT code 69210.  Three encounters out of the 200 supported the CPT code 69210.  The rest were "ear flushes" done by a LPN.  The three encounters that did support CPT code 69210 documented that the ear was impacted and a currette was used by a physician.  Refunds will be made going back six years and education will be provided to the providers.  

Respectfully,

Barbara A. Love, CPC, CPC-H, CMSCS, CBCS


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## valdenise

Mrssnail

Please send me a copy of the Nov 2005 Coding Institute, in regards to code 69210...thank you..
Valerie
*Valdenise38@yahoo.com*


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## jbagsic

can i get a copy too? jazelbagsic@gmail.com


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## MLBradshaw

Please send me a copy of the 2005 publication on ear lavage in conjunction with an office visit.   I'm performing an audit and need this information for support.   Thanks very much for your response.


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## mitchellde

Also the coders desk reference sets out a description for this procedure that states the physician must use a scoop or a currett.  I also give as a reminder that this code is in the surgical section of the book and with only a few exceptions such as venipuncture codes in the range of 10000-69999 are to be performed by physicians.


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## b.cobuzzi

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._


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## dcraven

*Cpt 69210*

For Medicare - What are your opinions on the following taken from the LCD 
L25143 for CPT 69210 (Region IV)

*Indications and Limitations of Coverage and/or Medical Necessity*
Impacted cerumen removal involves the extraction of accumulated hardened cerumen from the external auditory canal *by any means including irrigation*, use of a curette, and/or operating microscope.

For billing a Medicare patient how would you interprete the above?  It actually states any method including irrigation.


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## dcraven

*Cpt 69210*

For Medicare - What are your opinions on the following taken from the LCD 
L25143 for CPT 69210 (Region IV)

Indications and Limitations of Coverage and/or Medical Necessity
Impacted cerumen removal involves the extraction of accumulated hardened cerumen from the external auditory canal by any means including irrigation, use of a curette, and/or operating microscope.

For billing a Medicare patient how would you interprete the above? It actually states any method including irrigation. 
__________________
Debby


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## b.cobuzzi

*Removal of Impacted Cerumen*

I think it's rather generous of them and it is not consistent with other LCD's from other MACs.  

I'd refer you to the American Academy of Otolaryngology's CPT for ENT article on this: http://www.entnet.org/Practice/upload/Cerumen-Removal.pdf 

And their policy statement: http://www.entnet.org/Practice/policyCerumenRemoval.cfm


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