Pediatric Coding Alert

Question: Which code will replace 380.4 (Impacted cerumen) under ICD-10?

Answer: You’ll have more than one replacement for 380.4, and you may have to scrutinize the operative report for which ear was addressed before you can identify the right code.

Under ICD-10, you’ll look to the H61.2- (Impacted cerumen) series of codes when a patient presents with impacted ear wax. The fourth digit will specify the affected ear, as follows:

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

Documentation: Pediatricians typically make a diagnosis of impacted cerumen by examining the patient’s ear canal and eardrum with an otoscope. Providers will need to be more detailed in their documentation of impacted cerumen by noting which ear is affected, and in cases when both ears are addressed, you’ll pinpoint H61.23 as the appropriate code.