Internal Medicine Coding Alert

Question: Can you explain how we know whether to report a procedure or E/M code for ear wax removal?

Rhode Island Subscriber

Answer: Checking how your provider removed the ear wax will point you toward the correct codes.

One option is 69210 (Removal impacted cerumen [separate procedure], 1 or both ears). But you must meet certain criteria before submitting 69210:

• The medical provider/physician must perform the service
• The provider must use some type of tool when removing the wax (an otoscope and wax curettes, forceps, and/or suction)
• The medical provider must document that the cerumen is impacted.

Irrigation with saline or peroxide does not constitute using 69210. If the provider removed the wax by lavage, you cannot report 69210. Instead, submit 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) if a nurse provided the service or 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) if the physician only performs the lavage with no other services.