Bill only one time.
A major element in determining whether code 69210 should be reported is understanding the definition of impacted cerumen. By definition “ if any one of the following are present, cerumen should be considered impacted”:
1. Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.
2. Extremely hard, dry, irritative cerumen causing symptoms such as pain, itiching, hearing loss.
3. Inflammatory conditions, infection or dermatitis
4. Obstructive cerumen that cannot be removed without magnification and multiple instrumentation.
Description of CPT 69210
Under direct visualization, the physician removes impacted cerumen using suction, a cerumen spoon or delicate forceps, if no infection is present, the ear canal may be irrigated.
A simple ear lavage, performed with water and bulb syringe, is considered inclusive with the office visit and is not to be billed.
Appropriate coding of unscheduled, cerumen impaction removal along with Evaluation and Management:
Example
99213-25
69210-59
