Otolaryngology Coding Alert

Hint: removal method is key.

When a patient presents to the clinic for cerumen (earwax) removal, there are a number of methods the provider might use in order to treat the patient.

The treatment could range from a simple nonsurgical swabbing of the ear all the way to surgical removal of the cerumen with instruments.

Think you know how to code the different methods of cerumen removal? Here’s a case study to test yourself, along with some advice on choosing the correct codes.

Case study: A patient presents with severe left ear pain and hearing loss. During the evaluation and management (E/M) service, the provider inspects the ear with an otoscope and discovers 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.

Look to Whether Wax Was Impacted

Whenever you’re coding for cerumen removal, you first need to find out whether the wax was impacted. This detail has a direct impact on correct procedure coding.

“Typically this can be identified through simple inspection or through use of an otoscope, which lets you see a little deeper into the ear and provides a little magnification; in other words, an [evaluation and management] E/M,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

According to CPT^® Assistant, Vol. 26, No. 1, impacted cerumen is defined in any of the following ways:

• 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.

The provider needs to know whether the cerumen is impacted or not because this will directly impact the removal method they choose, and the diagnosis and procedure codes reported. For example, if the cerumen is not impacted and can simply be wiped away with a swab, that work is considered part of the standard E/M service and is therefore not separately billable, Bucknam explains. For this, you’ll report a code such as 99202/99212 (Office or other outpatient visit for the evaluation and management of a/an new/established patient, which requires … straightforward medical decision making …).

However, in this case study, the provider documented cerumen impaction in the left ear, which narrows your options for coding the removal to 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) or 69210 (Removal impacted cerumen requiring instrumentation, unilateral).

As described earlier, instrumentation the provider might use during cerumen removal includes forceps and curettes; they might also use suction, a wire loop, or a hook to remove ear wax. The procedure “might also involve some lavage, which is not separately billable,” explains Bucknam.

Pay Attention to Removal Method

The second key factor in determining which code to report is the method of removal utilized. If the provider removes impacted cerumen using irrigation and/or lavage without instrumentation, you’ll report code 69209. If the impacted cerumen removal requires the provider to use instrumentation, you should use code 69210.

According to the documentation in the case study, the provider successfully removed the cerumen using a wax curette and cup forceps. Thus, the correct code for the removal of impacted cerumen in this patient is 69210 — with modifier LT (Left side) appended, depending on payer preference.

Check the chart notes: Make sure the documentation indicates the effort, skill, and equipment required to provide the service.

Document the Most Accurate Diagnosis Code

In order to report 69209 or 69210, you’ll need a diagnosis of impacted cerumen, as the CPT^® descriptor indicates. The ICD-10 codes that you’d report for impacted cerumen are:

• H61.20 (Impacted cerumen, unspecified ear)
• H61.21 (Impacted cerumen, right ear)
• H61.22 (Impacted cerumen, left ear)
• H61.23 (Impacted cerumen, bilateral)

In this patient, only the left ear was affected by cerumen impaction, so you’ll report H61.22. “Note that the 5th digit of the diagnosis is consistent with the modifier used with the CPT^® code,” notes Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare Solutions of Tinton Falls, New Jersey.

Report the Correct CPT^® Codes

So, we’ve assessed that you’ll report 69210-LT for the procedure and H61.22 to justify the procedure, but we can’t stop there.

If you look back to the details in the case study, you’ll notice that the provider performed an E/M service, used an otoscope to see deep into the ear, and discovered impacted wax — the procedure findings caused the treatment plan to change. Thus, the physician proceeded with a cerumen removal procedure, which required additional work; therefore, you should report both it and the E/M service to accurately represent the full extent of the services.

That being said, for this claim, you’d submit:

• 69210-LT for the cerumen removal
• An appropriately leveled E/M code, such as 99212
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure …) appended to the E/M code to show that a significant, separately identifiable E/M preceded the cerumen removal.
• H61.22 linked to 69210 and 99212 to represent the impacted cerumen.

“Different diagnoses are not required for the E/M service to be reported on the same date,” said Dottie Davis, CPC, COC, CGSG, CEMC, CPMA, team lead coder at MedKoder, LLC, in her session “ENT Procedure and Surgery Coding” at HEALTHCON 2024. If an office visit and procedure are performed for the same diagnosis but your treatment plan changes after you do a procedure, you’ll be able to use modifier 25 — both services are reportable, provided the additional decision making is documented, she explained.

“However, there is a good chance that a third-party payer will deny the 25-modified E/M service along with the 69210 with the same diagnosis, feeling that the patient came to the physician just to have their impacted cerumen removed,” says Cobuzzi. “Remembering the note, the patient arrived complaining of severe pain on the left side and hearing loss. Although these are signs and symptoms, and ICD-10 indicates that once the cause of the symptoms is found, the cause should be used as the definitive diagnosis, it is recommended to link these chief complaints to the E/M service and then link the impacted cerumen to the removal procedure to provide the third-party payer a better picture of the encounter. This informs the payer that the encounter was not just for the removal of the impacted cerumen and that there is a reason for a significant and separately identifiable E/M,” she explains.

Let These Examples Shed Light on Including E/M With -25

Knowing when you can and cannot bill impacted cerumen removal (i.e., 69210) and an E/M with modifier 25 is crucial to ensure correct ENT coding. So let’s review two examples that further help demonstrate this concept.

Scenario 1: When a patient has another treated diagnosis. They have cerumen impaction, but they also have other diagnoses that the provider is treating them for, such as chronic sinusitis or allergic rhinitis. “You’re seeing them for chronic sinusitis, and you’ve got the cerumen impaction, and you do the removal … you can add the E/M with the 25 modifier on for that,” explained Davis.

Scenario 2: When a patient comes in for routine ear cleanings. In this case, you would only bill the procedure because you already know what they are there for. Davis expounded, “At the end of a visit the doctor says, come back in a month for your cleaning again — there are no additional E/M services happening, they’re just coming in for their cleaning every month or two months. So you should only bill for the procedure when they come in.” In this scenario, it would not be appropriate to bill an E/M with modifier 25.