Wiki 69210 Cerumen removal

[chesmith]

How would you code the follow situation:
Doctor uses curette to remove impacted wax. During the procedure the dr. is not able to remove the curette. They then resort to an ear flush or lavage and the impacted wax is successfully removed.

1) can I code this with 69210 since the dr. spent time trying to remove wax with curette?

2) Is this now coded as a wash/lavage since that is how the final wax was removed?

thank you for your input

 

[ehanna]

How would you code the follow situation:
Doctor uses curette to remove impacted wax. During the procedure the dr. is not able to remove the curette. They then resort to an ear flush or lavage and the impacted wax is successfully removed.

1) can I code this with 69210 since the dr. spent time trying to remove wax with curette?

2) Is this now coded as a wash/lavage since that is how the final wax was removed?

thank you for your input

You can bill the 68210 because Dr. documented usage of the currette. Often flushing/lavage is used in conjunction with the currette.

 

[Candice_Fenildo]

If the provider does not use instrumentation to remove the wax, you should count the documentation as part of the office visit code. Use the documentation to select the appropriate office visit code: 99201?99205 for a new patient or 99211?99215 for an established patient.

Removal only by lavage, cotton swab, or drops does not support 69210.

This was taken directly off the AMA CPT Assistant and the AAO-HNS Website

 

[chesmith]

So what is the correct answer????
The doctor did use the tool, it just didn't remove the ear wax. That is why they resorted to the flush/lavage.
1) should it be a 69210 with a Modifer for reduced services?
2) should it be a 69210?
3) should it be an office visit and no 69210?

Some how the doctor should be able to charge for the time spent trying to remove wax with the tool. It was documented as being used but not successful!