Part B Insider (Multispecialty) Coding Alert

Question: A patient came into our office and noted earwax removal as her chief compliant. Document-ation describes the wax as impacted because it completely covers the eardrum and causes the patient hearing loss. Her primary-care physician removed the impacted cerumen with magnification provided by otoscope and instruments such as wax curettes, forceps and suction. Which code should I report?


Arizona Subscriber


Answer:  Report CPT 69210 (Removal impacted cerumen [separate procedure], one or both ears) for removal of only impacted cerumen (380.4, Impacted cerumen), instructs the July 2005 CPT Assistant.

Training tip: To help your staff determine whether a case involves impacted cerumen, use the following definition, offered by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). "Code 69210 does not mean 'simple' impaction such as one that might be addressed through irrigation," says Linda J. Taliaferro, MHCM, director of regulatory and socioeconomic affairs at AAO-NHS in Alexandria, VA. Internists should consider cerumen impacted if any one or more of the following conditions are present:

• Visual: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle-ear condition.

• Qualitative: Extremely, hard, dry, irritative cerumen causing symptoms such as pain, itching and/or hearing loss.

• Inflammatory: Associated with foul odor, infection or dermatitis.

• Quantitative: Obstructive, copious cerumen that requires a physician's skill to remove with magnification and multiple instrumentations.

Keep in mind: For an encounter to qualify for 69210, a physician must use instrumentation to remove impacted cerumen. The American Medical Association adopted this new policy from many Medicare carriers' guidelines. "Medicare carriers have always had pretty strict interpretations regarding the payment of 69210," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, MO. The AMA's new guidance more closely aligns CPT with carriers' policies.

Bottom line: You should report 69210 when the encounter meets both these criteria:

1. Patient has cerumen impaction.

2. Removal requires physician work using at least an otoscope and instrumentation, rather than just
simple lavage.