For 2016, Current Procedural Terminology (CPT ®) code 69209 Removal impacted cerumen using irrigation/lavage, unilateral was created. In order to help Otolaryngologist – Head and Neck Surgeons correctly code, the Academy helped the American Medical Association (AMA) draft a CPT Assistant article on the removal of impacted cerumen. The AMA CPT Assistant article “Removal of Impacted Cerumen,” can be found on page 7 of the January 2016 CPT Assistant.
In CY 2014, CPT 69210 was revised to clarify that the code is unilateral and in order to be reported, physicians must use some type of instrumentation (discussed further below) and may not remove ear wax solely by irrigation or lavage. The current CPT descriptor for 69210 is as follows:
69210, Removal impacted cerumen requiring instrumentation, unilateral
Irrigation / Lavage:
Payers typically will not cover simple, non-impacted earwax removal. This work is included in the E/M service and should be reported with an E/M code. Further, if earwax is removed by irrigation or lavage only, CPT 69210 should NOT be reported. New in 2016 is CPT code 69209 Removal impacted cerumen using irrigation/lavage, unilateral which may be used to report use of lavage or irrigation and represents practice expense only.
Requirements for reporting 69210:
The AAO-HNS and CPT define cerumen as impacted if any one or more of the following conditions are present:
- Cerumen impairs the examination of clinically significant portions of the external auditory canal, 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 of any consistency that cannot be removed without magnification and instrumentation requiring physician skills.
What is meant by Instrumentation?
Another 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.
Unilateral Procedure
Additionally, the descriptor of 69210 has been clarified to reflect that the code is inherently unilateral. For bilateral impacted cerumen removal, report code 69210 with modifier 50, Bilateral Procedure, appended.
NOTE: Despite the CPT coding change to 69210, CMS issued a payment policy within the 2014 final Medicare Physician Fee Schedule which refuses to acknowledge the use of the -50 modifier when 69210 is furnished bilaterally. Their rationale for this is that CMS feels the physiologic processes that create cerumen impaction likely will affect both ears. Per CMS instruction, this reimbursement policy will remain in place through CY 2014 as an interim value for the service for 2014. Based on CMS’ guidance, the Academy recommends that members NOT report 69210 using modifier -50, as MACs are denying these claims entirely and not paying for even one unit reported. We also have confirmation from members that some private payers are following CMS’ policy on this issue and are not reimbursing for this as a bilateral procedure. We encourage providers to check with their private payers, as policies vary and there are some who are allowing the -50 modifier.
Requirements for reporting 69210 with an E/M on the same date of service
When reporting an E/M visit and cerumen removal on the same date of service (DOS), the following criteria must be met: 1. The initial reason for the patient’s visit was separate from the cerumen removal. 2. Otoscopic examination of the tympanic membrane is not possible due to the impaction; 3. Removal of the impacted cerumen requires the expertise of the physician or non-physician practitioner and is personally performed by him or her; and 4. 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.
Modifier -25
When all of the above conditions are met, an applicable E&M and 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 your clinical notes demonstrate that the E/M and the cerumen removal are separate services and that all elements of the applicable E/M service are satisfied. Finally, it is important to include the applicable ICD-10 diagnosis code on the claim.
Reporting Add-on Code +69990 with CPT 69210
Add-on code +69990, Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure), should not be reported if the operating microscope is used for cerumen removal. In this later instance, however, code 92504, Binocular microscopy (separate diagnostic procedure), may be reported additionally.
Reporting Code 92504 with CPT 69210
For CY 2014, 69210 no longer includes the use of the microscope. As such, code 92504, Binocular microscopy (separate diagnostic procedure) can be reported in addition to 69210 if the operating microscope is used for cerumen removal. Despite the removal of microscope from 69210’s descriptor, many payers will still not allow reporting of 92504 separately when reporting 69210.
Audiologists Reporting 69210
Finally, Medicare will not cover cerumen removal performed by an audiologist. For Medicare patients, only the physician should bill 69210 when removing cerumen on the same day as audiology testing. Some carriers might require the HCPCS code G0268. Also, remember that G0268 is a bilateral procedure and should be reported with one unit of service, even if both ears were cleaned. Independent audiologists cannot bill 69210.
Revised October 2023
