Removal of impacted cerumen is represented by the following two CPT codes:
- 69209 – Removal impacted cerumen using irrigation/lavage, unilateral
- 69210 – Removal impacted cerumen requiring instrumentation, unilateral
Payers typically will not cover simple, non-impacted earwax removal. This work is included in E/M services and should not be reported separately with E/M services when performed. If impacted earwax is removed by irrigation or lavage only, use CPT 69209. CPT 69210 should NOT be reported for lavage.
Requirements for reporting cerumen removal:
CPT defines cerumen as “impacted” if one or more of the following conditions are present:
• cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanic membrane (unable to see the entire tympanic membrane), or middle ear condition;
• extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, hearing loss, etc.;
• cerumen is associated with foul odor, infection, or dermatitis; or
• obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician or non-physician practitioner skills.
A key factor in determining whether code 69210 should be reported is what instruments are utilized to remove the impacted ear wax. In this context, instrumentation is defined as the use of an otoscope and other instruments such as wax curettes, wire loops, or suction plus specific ear instruments (e.g., cup forceps, right angle hook). Accompanying documentation should indicate the equipment required to provide the service.
The descriptors for codes 69209 & 69210 indicate that they are unilateral codes. For bilateral impacted cerumen removal, report these codes with modifier 50, Bilateral Procedure, appended.
Note: Medicare does not allow the use of modifier 50 for impacted cerumen removal. To report to Medicare use unilateral code with no modifier whether performed unilaterally or bilaterally.
Requirements for reporting impacted cerumen removal with an E/M on the same DOS
When reporting an E/M visit UandU cerumen removal on the same date of service, the following criteria must be met:
• The main reason for the patient’s visit was separate from the cerumen removal
• Otoscopic examination of the tympanic membrane is not possible due to the impaction
• Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner
• The procedure requires a significant amount of time and effort, and all of the above criteria are clearly
documented in the patient’s medical record
When all of the above conditions are met, an applicable E/M and 69209 OR 69210 may be reported together and the appropriate modifier, -25 (significant and separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the E/M visit code. It is imperative that clinic notes demonstrate that the E/M and the cerumen removal are separate services.
CPT guidelines indicate: “For cerumen removal that is not impacted, see E/M service code …” such as new or established office patient (99201-99215), subsequent hospital care (99231-99233), etc. In other words: if the earwax isn’t impacted, removal is included in the documented E/M service reported and may not be separately billed.