Primary Care Coding Alert

Question: If a provider performs an ear lavage and uses instrumentation on both ears, do I use 69209-50 or 69210-50?

New Jersey Subscriber

Answer: The answer to this question depends on a number of factors.

First, you do not say whether the provider performed the ear lavage to remove impacted cerumen in the patient’s ear. If the cerumen was not impacted, then you cannot choose either 69209 (Removal impacted cerumen using irrigation/lavage, unilateral) or 69210 (Removal impacted cerumen requiring instrumentation, unilateral). Instead, CPT^® guidelines instruct you to use an appropriate evaluation and management (E/M) code from 99202-99205 or 99212-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …).

If the cerumen removed in the encounter is indeed impacted, which you must document with H61.20 (Impacted cerumen, unspecified ear), H61.21 (… right ear), H61.22 (… left ear), or H61.23 (… bilateral), you must then choose the CPT^® code that most closely described the actual procedure your provider performed. As your provider used instrumentation, you cannot use 69209 even if they performed irrigation prior to the instrumentation removal.

Last, CPT^® instructs you to use modifier 50 (Bilateral procedure) if the removal is bilateral. However, modifier choice in this example is payer specific. Some may want you to report bilateral cerumen removal on two lines with modifier 50 on the second line. Others may also prefer two lines with the RT modifier on one line and the LT modifier on the other. So, you will have to check payer guidelines before submitting your claim for this service.