# Lavage for removal of infected material?



## treinemer (Apr 21, 2017)

​Hi all, 

I have a provider that is insistent that there is a code for ear lavage for other than impacted cerumen. I am not able to find anything other than bundled to the E/M and the ENT coder in our system is not available to ask. 

This is his question-
Can you reach out to ENT to see what they use?  This is standard procedure that I suspect they bill for.  Lavage and removal of infected material from the ear. 


Chart note-

Chief Complaint
Patient presents with
•	Hearing Loss
*	*	minimal discharge, denied pain, bilateral, URI symptoms last month however ears never improved 
*
Patient presents today for 1 month of progressive hearing loss and mild BL ear discharge. Just got back from Mexico- down there for several months. 
*
No clear triggers, had progressive hearing loss. Every so often will have a very transient pain- but otherwise no pain. Ears do not feel blocked. No f/c. Feels like he has lost about 50% of his upper end hearing. 
*
ROS
HENT: Positive for ear discharge, ear pain and hearing loss. Negative for congestion, sore throat and tinnitus. 

Exam
HEENT: Oropharynx clear, mucous members moist, no lymphadenopathy in supraclavicular, submandibular, cervical chains. Cranial nerves are intact bilaterally, with the exception of slightly decreased hearing bilaterally. Bilateral tympanic membranes are white, covered with a fuzzy material. This appears fairly dry, without significant discharge. There actually appears to be some mycelia growing from the base of the external auditory canal. Otherwise the canal is fairly open without apparent irritation.
After lavage, his tympanic membranes were now visible, what I thought were his tympanic and brains initially were actually a coating of mycelium obstructing his external auditory canal. His external auditory canal is quite pink and raw, with some swelling near the tympanic membrane. Tympanic membrane itself appears to be healthy and intact without bulging or erythema. Hearing improved after lavage
*
Assessment and Plan:
1. Other infective chronic otitis externa of both ears
This appears to be otomycosis of his external ears. Primary treatment with lavage however he does need eardrops. Will use clotrimazole solution after review of literature, 3 drops in each ear twice a day ×14 days, and that he should follow-up for reevaluation. He should also use acetic acid/hydrocortisone solution in his ears as below 3 times a day for 5 days as well.
- clotrimazole (LOTRIMIN) 1 % external solution; Apply 4 drops to each ear twice a day for 14 days, then come back in for re-assessment. Dispense: 30 mL; Refill: 0
- acetic acid-hydrocortisone otic drops; Place 5 drops into both ears 3 (three) times daily Dispense: 10 mL; Refill: 1

Thanks!


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## JenniferB7 (Apr 21, 2017)

You are correct.  Ear lavage is bundled into the E/M service.  

There is a code 69209 for _removal of impacted cerumen using irrigation/lavage, unilateral_; however, the parenthetical notes in CPT specifically state:  "For cerumen removal that is not impacted, see E/M service code."   It is easily inferred that a simple lavage of infected material would also be bundled into the E/M service.    From a coding perspective, the removal of infected material is no different than removal of non-impacted cerumen.   You can always provide your physician with the article from the CPT Assistant, October 2013:

CPT Assistant Archives - Coding Update: Auditory System (69210) (October 2013, page 14)  

Auditory System code 69210, Removal impacted cerumen requiring instrumentation, unilateral, is revised in the Current Procedural Terminology (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 ear wax removal and the appropriate CPT codes to report once the 2014 revisions become effective:


The patient presents to the office for the removal of ear wax by the nurse via irrigation or lavage.
*The patient presents to the office for the removal of ear wax by a physician (any specialty) via irrigation or lavage.*
The patient presents to the office for ear wax 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*. 

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.​
I hope that helps!


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## thelton (Apr 24, 2017)

I have a physician asking if he can order a lavage for impacted cerumen, have his nurse perform it, and still bill 69209 or would he have to personally perform the lavage?  Thoughts please?


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## JenniferB7 (Apr 24, 2017)

thelton said:


> I have a physician asking if he can order a lavage for impacted cerumen, have his nurse perform it, and still bill 69209 or would he have to personally perform the lavage?  Thoughts please?



Yes.  Make sure that the physician documents "impacted cerumen" and that the nurse thoroughly documents the procedure as well as his/her credentials showing that they are "qualified" to perform the lavage.   

CPT Assistant Archives - Surgery: Auditory System (Q&A) (February 2016, page 14)  

Question: Who may perform the procedure described by code 69209, Removal impacted cerumen using irrigation/lavage, unilateral? In addition, does it require the use of instrumentation and magnification?

Answer: The procedure described by code 69209 may be performed by a physician or any qualified health care professional, including clinical staff. The procedure does not require the use of instrumentation and/or magnification. When the removal of impacted cerumen requires instrumentation, report code 69210, Removal impacted cerumen requiring instrumentation, unilateral. Note: For cerumen removal that is not impacted, report an E/M service as appropriate.​
Hope that helps!


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## thelton (Apr 25, 2017)

Thank you Jennifer!


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## treinemer (Apr 25, 2017)

Thank you


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## JenniferB7 (Apr 25, 2017)

You are both very welcome!


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