Primary Care Coding Alert

Hint: removal method is key.

Removal of ear wax, or cerumen, is one of the most common in-office procedures seen in the primary care setting. Coding for the procedure is not difficult once you understand a few of the nuances.

Whether you’re new to coding, or consider yourself a seasoned pro, here’s a case study to walk you through coding a cerumen removal encounter.

Case study: A patient presents with severe left ear pain and hearing loss. During the evaluation and management (E/M) service, the provider inspects the ear with an otoscope and discovers a significant amount of impacted cerumen. Encounter notes indicate that the cerumen is dry, hardened, and discolored. Due to the hardness of the cerumen, the provider uses a curette and forceps to remove it.

Look to Whether Wax Was Impacted

Whenever you’re coding for wax removal, first find out whether the wax was impacted. This detail has a direct impact on correct procedure coding.

“Impacted cerumen can be diagnosed via an E/M by direct visualization with an otoscope,” explains Brenda Stevens, COC, CPC, CDEO, CPMA, CRC, CPC-I, CMC, CMIS, CMOM, 2022 AAPC Chapter Association BOD Chair (AAPCCA BOD Region 2 Atlantic: PA, NJ, DE, MD), auditor/coder/educator at medKoder in the Philadelphia area. According to CPT^® Assistant, Vol 26, No 1, Impacted cerumen is defined as having any of the following:

• Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.
• Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.
• Inflammatory considerations: Associated with foul odor, infection, or dermatitis.
• Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.

The provider needs to know whether the cerumen is impacted or not because this will directly impact the removal method they choose and the code(s) reported. For example, if the cerumen is not impacted and can simply be wiped away with a swab, that work is considered part of the standard E/M service and is therefore not separately billable. For this, you’ll report a code such as 99202/99212 (Office or other outpatient visit for the evaluation and management of a/an new/established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making…).

However, in this case study, the provider documented 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).

Pay attention to Removal Method

The second key factor in determining which code should be reported is the method of removal 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.

Note: Even though the service described by 69209 is typically done by clinical staff and does not include physician work relative value units (RVUs), this service is separately reportable from the E/M service. This is because irrigation/lavage requires clinical staff time and other practice expenses that go beyond those in the regular E/M.

According to the documentation in the case study, the provider successfully removed the cerumen by using a wax curette and cup forceps. Thus, proper billing for the removal of impacted cerumen in this patient is 69210-LT (Left side).

Documentation alert: Make sure the documentation indicates the time, effort, and equipment required to provide the service.

Remember to Document the Accurate Diagnosis Code

In order to report 69209 or 69210, you’ll need a diagnosis of impacted cerumen, as the CPT^® descriptor indicates. The ICD-10 codes that you’d report for impacted cerumen are:

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

For this patient, the cerumen affected the left ear, so you’ll report H61.22.

Report the Correct CPT^® Codes

So, we’ve assessed that you’ll report 69210-LT for the procedure and H61.22 to justify the procedure, but we can’t stop there.

If you look back to the details in the case study, notice that the provider performed an evaluation and management (E/M) service, used an otoscope to see deep into the ear, discovered the impacted wax, and proceeded with a removal procedure. The removal of the cerumen required additional work, and therefore you should report both the E/M service and the procedure to accurately represent the full extent of the services.

That being said, for this claim, you’d report:

• 69210-LT for the cerumen removal
• An appropriately leveled E/M code, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making…)
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) appended to 99212 to show that a significant, separately identifiable E/M preceded the cerumen removal.
• H61.22 appended to 69210 and 99212 to represent the impacted cerumen.

Check Payer Preferences for Potential Modifiers

Whenever you’re dealing with either 69209 or 69210, realize they are considered unilateral codes. This means that when your provider 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. Absent payer preference to the contrary, you should use modifier 50, which is what CPT^® instructs you to use when either procedure is done bilaterally.

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.