Pediatric Coding Alert

Question: Our pediatrician removed cerumen from a patient’s left and right ears. The cerumen was not impacted. Can I use 69209 or 69210 for the removal with modifier 52 to show the procedure was changed because the cerumen was not impacted and modifier 50 to show the procedure was performed on both ears? Also, should I use H61.2- for the diagnosis?

Oregon Subscriber 

Answer: As the patient’s cerumen was not impacted, you cannot use 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) or 69210 (Removal impacted cerumen requiring instrumentation, unilateral). The codes are exclusively used for removal of impacted cerumen, which is not the case in this scenario.

And you certainly cannot use modifier 52 (Reduced services) in this case because it indicates that your provider has partially reduced or eliminated a part of the service. Use of the 52 modifier here changes the description of the procedure to such an extent that you would be fundamentally misrepresenting the service your physician has provided.

Your use of modifier 50 (Bilateral procedure) would be correct if your pediatrician did use 69209 or 69210, however. Both CPT^® and Medicare guidelines instruct you to use modifier 50 with 69209 and 69210, though some private payers do not follow these guidelines and may prefer you to report bilateral cerumen removal with the RT (Right side) modifier on one line and the LT (Left side) modifier on the other.

As you cannot report 69209 or 69210 in this scenario, you will need to follow CPT^® guidelines for both codes, which state “for cerumen removal that is not impacted, see E/M service code.” In this case, you would use the appropriate evaluation and management (E/M) code from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

Similarly, for the diagnosis, you cannot use H61.2- (Impacted cerumen) because your pediatrician did not document that your patient’s cerumen was impacted. To pinpoint the exact code, you will have to go back into your provider’s notes, or query your provider, to determine the exact nature of the patient’s condition at the time of the service. Typically, in cases of ear wax removal, the patient’s chief complaint will be something like H92.0- (Otalgia), more commonly known as earache, or H93.1- (Tinnitus).