Revenue Cycle Insider

Question: Are multiple procedure codes required for a physician to both diagnose and treat cerumen impaction?

Illinois Subscriber

Answer: Whether the diagnosis and treatment of an impacted cerumen can be covered by a single evaluation and management (E/M) code depends upon the tool(s) the physician uses.

As you may know, cerumen is also known as earwax, and a buildup of the substance can lead to discomfort, itching, pain, trouble hearing, or tinnitus in the affected ear.

There are several ways a clinician may diagnose and treat cerumen impaction, beginning with using an otoscope to see what’s going on in the ear. This is usually considered part of the E/M service. If the earwax can simply be wiped away with a swab, it may not be impacted — and the service is probably also part of the E/M. If this encounter happens in a doctor’s office, E/M codes 99202/99212 (Office or other outpatient visit for the evaluation and management of a/an new/established patient, which requires … straightforward medical decision making …) may be appropriate.

If the encounter happens in an emergency department (ED), ED E/M codes 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) may be your choice.

If the clinician needs to use a different method, like lavage or irrigation, to remove the cerumen, you may need to code a different service. Use of lavage could be coded with CPT^® code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral). If lavage isn’t sufficient, the clinician may resort to instrumentation, using forceps, suction, or curettes, which would be coded as 69210 (Removal impacted cerumen requiring instrumentation, unilateral). If the clinician uses lavage or irrigation in addition to the instrumentation, the procedures aren’t separately codable.

Remember to add relevant diagnosis codes to support your procedure codes on your claim.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC