# cerumen removal now being denied for medicare and horizon



## afskevvy@comcast.net (Jun 3, 2015)

We have been reimbursed in the past for an office visit (99213 with modifier 25) and wax removal (69210) when the patient presented with other conditions. Recently, insurance companies are denying the 69210 wax removal code and are bundling it with the e/m code. Any ideas?


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## mitchellde (Jun 3, 2015)

It is all related to the dx codes used, the reason for the visit, and the fact that audits have shown that the 69210 code is often used incorrectly.   If the documentation does not contain a procedure note indicating the use of a scoop or curette then the code should not be used.  If the documentation does not support that this was to be of therapeutic value to the patient it should not be used.  In other words if the provider performed the removal to afford a better look, then this was for the providers benefit not the patient and not billable.  
After audit results have indicated rampant misuse of a code the payer will regularly deny claims with the codes expecting that you will appeal with correct documentation if you have it.


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## Vcurtis11 (Jun 3, 2015)

Note the description change of the code 69210 for Jan 2014.  The description states which equipment must be used.  Just a simple squirting water in the ear to remove the wax doesn't qualify.


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## mrsjehu (Jun 3, 2015)

I believe medicare changed to only allowing 1 per lifetime. Since last year we have not been able to get paid for removal of ear wax using tools.


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## Candice_Fenildo (Jun 4, 2015)

Okay, so rather than everyone chiming in with their "I thinks" and "opinion" ( except MichelleD) I thought I would attach the proper citations for clarification from the AAO-HNS and from CMS 

 Coding Update: Auditory System (69210)​ Auditory System code 69210,​_Removal impacted cerumen_​_
requiring instrumentation, unilateral,​_​is revised in the CPT​
2014 code set to include the use of instrumentation in the​ removal of impacted cerumen (ear wax) and to clarify that​ the procedure is unilateral. In collaboration with the​ American Academy of Otolaryngology-Head and Neck​ Surgery (AAO-HNS), this article discusses the following​ three coding scenarios related to earwax removal and the appropriate CPT codes to report once the 2014 revisions become effective:​ 1. The patient presents to the office for the removal of earwax by the nurse via irrigation or lavage.​ 2. The patient presents to the office for the removal of earwax by a physician (any specialty) via irrigation or lavage.​ 3. The patient presents to the office for earwax removal, which requires​ magnification provided by an otoscope or operating microscope, and instruments such as wax curettes, forceps, or suction by the primary care physician or otolaryngologist. This latter situation occurs most commonly when impacted cerumen completely covers the eardrum and the patient has hearing loss.​ ​* Question:​*​Are all of these procedures appropriately reported with CPT code 69210, Removal impacted cerumen requiring instrumentation, unilateral?​
* Answer: *No. Only the third scenario listed above would be reported 
with CPT code 69210. A major element in determining whether code 69210 should be reported is based upon an understanding of the definition of​_impacted _cerumen. The AAO-HNS defines cerumen as impacted if any one or more of the following conditions are present: ​ ​
? Cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition; 
? Extremely hard, dry, irritative  cerumen causes symptoms such as pain, itching, hearing loss, etc; 
? Cerumen is associated with foul odor, infection, or dermatitis; or 
? Obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician skills. 

Another key factor in determining whether code 69210 should be reported is what instruments are utilized to remove the impacted earwax. In this context, _instrumentation_ is defined as the use of an otoscope and other instruments such as wax curettes and wire loops, or an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angle forceps). 

Accompanying documentation should indicate the time, effort, and equipment required to provide the service. Additionally, the descriptor of code 69210 has been clarified to reflect that code 69210 is a unilateral code. For bilateral impacted cerumen removal, report code 69210 with modifier 50, _Bilateral Procedure,_ appended. 

Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting of code 69210. Rather, that work would appropriately be reported with an evaluation and management (E/M) code regardless of how it is removed (eg, lavage, irrigation, etc). therefore, based on this information, scenarios 1 and 2 would not be reported with code 69210. These scenarios would be reported with the appropriate E/M code. Scenario 3, however, would be reported with code 69210 because both criteria were met: the patient had cerumen impaction and the removal required physician work using an otoscope or other magnification and instrumentation, rather than simple lavage. ​ ​ Finally, an E/M code may be reported if there is a separate and distinct service performed at the same session. In that instance, modifier 25, _Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service, _should be appended to the E/M code. 
 ​
 ​


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## ollielooya (Jun 4, 2015)

Candice, these are the type of guidelines that provide hefty weight when having to navigate thru the appeals arena for denied claims when the above criteria is satisfied.  Thank you for sharing.  I'm sure this helpful thread will pop up for those utilizing the "search" function.  Very useful information!


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## afskevvy@comcast.net (Jun 15, 2015)

Thank you


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## afskevvy@comcast.net (Jun 15, 2015)

Thank you everyone for your input. I appreciate it.


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