Wiki 69210 Removal Impacted Cerumen (partial)

[Traci Watson]

What would be the correct coding for the following?

Scenario: Patient presents for removal of impacted cerumen. Impaction is confirmed on exam. Wax removal was attempted but unable to be fully completed to to patients discomfort.

 

[ChristinePhillips]

Cerumen removal

I would bill the procedure with a modifier -52 as long as you have documentation that the physician did attempt removal

 

[Traci Watson]

Thank you that makes sense.

 

[Mojo]

I would use modifier -53 if the intent was to complete the 69210 (the provider did not plan to perform a reduced procedure) and the procedure was discontinued due to threatening the well-being of the patient (pain).