Otolaryngology Coding Alert

Question: Patient presents with worsening of hearing in the left ear over the past several days. On examination, the otolar­yngologist cannot see the tympanic membrane due to obstructive copious impacted ear wax filling the EAC. The otolaryngologist documents left ear cerumen impaction and successfully removes the impacted cerumen using a wax curette and cup forceps. How is this coded?

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Answer: Proper coding depends on whether the ear wax removed was impacted. In this case, the otolaryngologist documents cerumen impaction in the left ear, which narrows your options for coding the removal to 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) and 69210 (Removal impacted cerumen requiring instrumentation, unilateral).

Coder’s note: If the ear wax is not impacted, then you will include the cerumen removal procedure as a component of an evaluation and management (E/M) service.

The second key factor in determining which code should be reported is the method utilized. For the removal of impacted cerumen using irrigation and/or lavage without instrumentation, report code 69209. When impacted cerumen removal requires the use of instrumentation (e.g., wire loop, wax curette, forceps, suction, hook) by a skilled provider, report code 69210.

Thus, proper billing for the removal of impacted cerumen in this patient is 69210-LT (Left side). Make sure the documentation indicates the time, effort, and equipment required to provide the service.

Diagnosis roundup: Don’t forget to include the appropriate ICD-10 code to help support your claim for the cerumen removal. Since this patient had cerumen impaction in the left ear only, you’d report H61.22 (Impacted cerumen, left ear).

Both 69209 and 69210 are unilateral codes, so when your ENT removes impacted cerumen from both ears, you may need to include a modifier such as -50 (Bilateral procedure) or -XS (Separate structure …) depending on payer preference.

Pro tip: “Medicare Part B treats these codes as if the description was ‘unilateral or bilateral’ even though that is not the description. If a cerumen impaction is removed bilaterally and billed to Medicare Part B as 69210-50 [Bilateral procedure], Medicare Part B will not pay the claim and consider the claim improperly coded. Medicare Part B expects this service to be coded 69210 with no modifier whether the impacted cerumen is removed from one ear or from both ears. Do not submit a claim to Medicare Part B with the 50 modifier for removal of impacted cerumen (69210),” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare Solutions of Tinton Falls, New Jersey.