ED Coding and Reimbursement Alert

Hint: If it’s not impacted, report an E/M code.

When a patient comes to the emergency department (ED) complaining of ear symptoms, the problem may be complex and require multidisciplinary care. But in some cases, the issue simply involves impacted earwax, also called cerumen. Even though this issue might sometimes seem simple, coding for it can create a wide range of questions.

Check out seven commonly asked questions about reporting claims for cerumen removal, along with expert answers.

1. How Is the Decision to Remove Cerumen Made?

Before a provider decides that the patient needs cerumen removed from the ear, the clinician first examines the patient’s ear canals. Typically, this can be done through simple inspection or through use of an otoscope, which lets the clinician see a little deeper into the ear and provides some level of magnification. In most cases, this occurs during an ED evaluation and management (E/M) service (99281-99285 [Emergency department visit for the evaluation and management of a patient …]).

2. When Is Cerumen Removal Part of the E/M Service?

If the cerumen is not impacted and can simply be wiped away with a swab or flicked out of the patient’s ear, that work is considered part of the standard E/M service and is therefore not separately billable. For this type of removal, you’ll report an E/M code without additional cerumen removal codes.

In black and white: “Generally, the simple/routine removal of cerumen (e.g., softening drops, use of cotton swabs and/or cerumen spoons) is considered a part of the office visit and therefore cannot be separately reimbursed on the same day as an E/M service,” says Blue Cross Blue Shield of North Carolina in its 2025 cerumen removal policy.

3. What Do Payers Consider ‘Impacted’ Cerumen?

According to CPT^® Assistant, impacted cerumen is defined as having any of the following characteristics:

• 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.

If the patient’s cerumen is impacted, then you can report a dedicated cerumen removal code from the following options:

• 69209 (Removal impacted cerumen using irrigation/lavage, unilateral)
• 69210 (Removal impacted cerumen requiring instrumentation, unilateral)

Keep in mind that both of the codes above apply to impacted cerumen removal only.

The Centers for Medicare & Medicaid Services (CMS) goes a step further, indicating in its >2026 policy that strict guidelines must be met before reimbursing cerumen removal.

According to CMS guidance, “Payment may be made only for:

1. “Medically necessary removal of symptomatic impacted cerumen;
2. “Medically necessary removal of impacted cerumen impeding the physician’s ability to properly evaluate or manage other signs, symptoms or conditions (e.g., examination of the tympanic membrane in cases of otitis media); or
3. “Medically necessary removal of impacted cerumen impeding a physician’s or audiologist’s ability to perform covered, medically necessary audiometry.”

In other words, you not only need to be able to demonstrate that the cerumen was impacted, but also that you had to remove it to examine the patient’s ears or perform medically necessary audiometry. While this is CMS’ policy, remember that other payers may have different payment criteria.

4. What Types of Irrigation/Lavage Apply to 69209?

Irrigation and lavage refer to using a continuous flow of liquid to loosen impacted cerumen. For instance, the provider might move saline or water into the ear, so it flushes out the earwax.

5. What Instrumentation Types Apply to 69210?

Instrumentation that the provider might use during cerumen removal described by 69210 includes forceps and curettes. They might also use suction, a wire loop, or a hook for cerumen removal.

6. What’s an Example of Each Removal Type?

69209: A 12-year-old patient presents to the ED complaining of difficulty hearing in their right ear, along with discomfort. The ED provider looks into the patient’s ear and can’t visualize their tympanic membrane due to impacted earwax. The provider pushes a syringe filled with lukewarm saline into the patient’s ear three times until the cerumen comes out of the ear. The appropriate ICD-10-CM code is H61.21 (Impacted cerumen, right ear).

69210: A 46-year-old patient presents to the ED with severe left ear pain and hearing loss. The provider cannot examine the patient’s ear properly due to a significant amount of impacted cerumen. Encounter notes indicate that the cerumen is dry, hardened, and discolored. Due to the hardness of the cerumen, the provider uses a curette and forceps to remove it. The appropriate diagnosis code is H61.22 (Impacted cerumen, left ear).

7. Can E/M Codes Be Reported With Cerumen Removal?

If the provider documented an E/M service that was necessary to make the decision to perform cerumen removal, you should report both the E/M service and the cerumen removal code to accurately represent the full extent of the services. In the ED, an E/M service is almost always performed before any procedure. Append 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) to the ED E/M code to show that a significant, separately identifiable E/M preceded the cerumen removal.

In black and white: “Payment may be made for both removal of impacted cerumen and an E/M service only if the E/M service represents a medically necessary, significant and separately identifiable service that is supported by medical record documentation,”CMS says.

Torrey Kim, Contributing Writer, Raleigh, North Carolina