Otolaryngology Coding Alert

Question: Can we report cerumen removal separate from an E/M service, or is the wax removal considered bundled into the evaluation service?

Ohio Subscriber

Answer: Great question. Simple removal of cerumen is considered included in the physician's E/M fee if the physician removed cerumen for visualization in the standard otolaryngology exam performed as part of a consultation.

Don't append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to a consult code and also report 69210 unless the patient has an "impaction." An impaction identifies a removal as nonroutine and is not considered part of a routine exam. Otherwise, simple removals are included in the history and physical portion of the exam.

Exception: You can separately charge for surgical wax removal (69210, Removal impacted cerumen [separate procedure], one or both ears) when a patient comes in specifically for wax removal. You can identify cerumen removals that merit 69210 when the physician documents having to soak the patient's ear and syringe the wax out, and when the physician must pick out hard, solid wax.

For patients who require regular cerumen-removal visits because of chronic impaction, you should only report 69210 for the first removal, then report the appropriate follow-up visit codes for the subsequent services.