Otolaryngology Coding Alert

Question: A patient arrived for an office visit for removal of cerumen in the right ear that the provided determined was impacted. The patient was in discomfort during the procedure and the provider documented that they could only partially remove the impacted cerumen, which resulted in a partial view of the tympanic membrane. Does this meet the criteria for 69210?

Utah Subscriber

Answer: The procedure does meet the criteria for 69210 (Removal impacted cerumen requiring instrumentation, unilateral) with modifier RT (Right side) reporting; however, you will need to append modifier 52 (Reduced services) to the code in order to convey to the payer that the procedure was not completed in its entirety. You are advised to submit this claim electronically to ensure proof of timely filing and again on paper. In box 19 of the CMS-1500 form, make sure to include the specific percentage of impacted cerumen removed along with the procedure documentation. Indicate on the paper claim that it is not a duplicate claim, but it is a claim for additional documentation. This will help give the payer a better gauge of what to reimburse the provider.