Primary Care Coding Alert

Question: Our clinician recently detected impacted cerumen in a patient with complaints of blockage in the left ear. Our clinician attempted to remove the cerumen through irrigation. However, only part of the cerumen could be removed; it could not be removed completely. Can a ‘cerumen removal’ code be reported? If so, should any modifier like 52 be reported with the service?

Texas Subscriber

Answer: When your clinician removes impacted cerumen through irrigation, you report the service with the CPT^® code 69209 (Removal impacted cerumen using irrigation/lavage, unilateral). However, in this case, your clinician only removed a small part of the impacted cerumen, and the service was not completed.

Since the service was not completed due to a complication that developed while it was being performed, you should report the procedural code with an appropriate modifier. Because the service was not a planned partial service that was performed by your clinician, it is probably best not to report it with modifier 52 (Reduced services) appended.

Since the procedure was halted (discontinued) because the impacted cerumen was very hard and your clinician could not proceed due to this complication that developed during the procedure, you should report the modifier 53 (Discontinued procedure) appended to the CPT^® code 69209. This will let the payer know that your clinician discontinued the procedure due to a complication. The documentation should mention the reason why your clinician had to discontinue the procedure after removal of a small amount of the cerumen.