# Cerumen Impaction



## dballard2004

I have a question regarding cerumen impaction and removal.  I am aware that if the physician performs a simple ear lavage, you can't use CPT code 69210.  The procedure is included in the E/M service.  In order to use the CPT code 69210, the cerumen must have been removed with some sort of instrumentation.  Does the removal with the insrumentation only have to be done by a physician to use 69210, or can a nurse perform the removal with instrumentation and use 69210?  Can someone please point me to written guidance on this issue, please?  Thanks.


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## RebeccaWoodward*

Two of our fellow CPC's provided this information at a different forum.

1) Auditory System, 69210 (Q&A) 

In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), 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 present, 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. 

2)

CPT Assistant July 2005 states "by a physician using at a minimum an otoscope and instruments" it also states that the wax must actually be impacted. Below is their criteria for impacted.
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.”

~I'm sure you'll get something from these~


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## dballard2004

Thanks.  This helps!


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## mburas

*Cerumen imaction removal*

I have a couple of questions.  
What has to be documented when doing this procedure?
Can A nurse do this procedure?

Example of what I am getting from the nurse or physician is  " wash ears- pt. tolerated well, No complications."


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