Wiki Cerumen Removal - The description for 69210

[ieshiarenee]

The description for 69210 clearly states "requiring instrumentation." My provider removed cerumen from a patient's ear using suction. Is this billable? I would code 92504 - Binocular microscopy (separate diagnostic procedure), but he doesn't state a microscope was used. I'm thinking this will be included in the physical exam. Any additional input is greatly appreciated.

Physical Exam
The patient was alert, fully oriented, in no acute distress, well nourished and well developed.
The right external ear was normal. The left external ear was normal. The right tympanic membrane was obscured partially by cerumen. Left canal patent, TM clear

The right external canal had a cerumen impaction. The left external canal was normal. The ear was cleaned by using suction. The procedure was successful.
Post-Procedure:
Patient Status: the patient tolerated the procedure well.
Complications: there were no complications. Cerumen removed from right canal

 

[casslouch]

He must state that a microscope was used, however this will be bundled anyway into the EWR.
Also the CPT book states that this code is used for impacted wax. Therefore I am not sure with the terminology the doctor noted would uphold in the case of an audit. I would check further into that.
My research gives me the understanding to bill out 69210 or G0268 the wax must be removed using a curette or other instrument. I would believe that to include suction.
Medicare does not pay this bilaterally regardless of modifier usage. Most other insurance required RT & LT to be used. Trial and error continue :~)

 

[Candice_Fenildo]

Suction is considered instrumentation. If the provider simply lavaged the ear, then that would NOT constitute CPT code 69210.

 

[Lynda Wetter]

Suction is considered instrumentation. If the provider simply lavaged the ear, then that would NOT constitute CPT code 69210.

Candice,
Do you happen to have any documentation the explains exactly what instrumentation is defined as?

 

[Sundancer]

Cerumen removal vs 69210

Candice,
Do you happen to have any documentation the explains exactly what instrumentation is defined as?

Oh, I would love some clarity on this, as well! I see this come up occasionally when auditing for both our Urgent Care centers and our medical group side.

What is considered Instrumentation? Does using a currette count as instrumentation? What type of suction counts? Manual/electronic?

Most of the encounters I've audited are only stating that ear was irrigated w warm water w or w/o peroxide. I've been telling my providers that they can't add the 69210 then unless they can document "Instrumentation" was used, and I've been removing it.

Thanks for any help