Listen Up for These Tips for Reporting

Cerumen Disimpaction
By Susan Dooley

After almost three months, some practices still report confusion about when to report the new cerumen
removal code for CPT 2016, 69209 (Removal impacted cerumen using irrigation/lavage, unilateral).
Who could blame them, given years of being told not to report a cerumen removal procedure unless
your provider uses instrumentation to disimpact the wax. Also, given the history with CMS and other
payers being reticent to reimburse for cerumen removal procedures, a little skepticism on the part of
providers and coders is certainly warranted. This procedure can be tricky to report because of strict
definitions of the term impacted, as well as limitations on when you can report an E/M and when you
can report the impaction removal procedures.

Tips for Billing 69209 for Ear Wax Removal With Lavage
First, be sure your cerumen removal procedure note clearly indicates that the ear wax was impacted and
that the procedure was medically necessary! According to the American Academy of Otolaryngology,
impaction is defined by a number of considerations:

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Visual: Excessive cerumen impairs examination of clinically significant parts of the external
auditory canal, tympanic membrane, or middle ear condition.
Qualitative: Cerumen is extremely hard, dry, irritated, and symptomatic, with pain, itching,
and/or hearing loss.
Inflammatory: Associated with foul odor, infection, or dermatitis.
Quantitative: Obstructive, copious cerumen requiring a physicians skill to remove with
magnification and multiple instrumentation.

Watch Your E/M Code Reporting

If your clinician inspects the patients ears during an exam, then irrigates the ear as part of the E/M
service, you probably wont be able to collect for both services unless you use a modifier and your
documentation proves that a medically necessary, significant, separately identifiable service was
performed. Paramount Healthcare, a payer in Ohio, explained that documentation should clearly
support that a significant amount of the clinicians time and effort were required, including a procedure
note supporting the time, the interventions, and how well (or not) that the patient tolerated the
procedure. Dont include the time spent removing the cerumen in the time spent performing the E/M
service, Paramount warns.

One Ear at a Time, Says CPT

As is clearly stated in their official descriptors, CPT codes 69209 and 69210 (Removal impacted
cerumen requiring instrumentation, unilateral) both describe unilateral procedures meaning just one
ear. If the patient underwent impacted cerumen removal from both ears, youd need to append
modifier 50 with a 1 in the unit field, according to Paramount. If you irrigated both ears to remove
impacted cerumen, this is how your claim would appear:

69209-50 linked to ICD-10 code H61.23 (Impacted cerumen, bilateral).

To make matters even more complicated, Medicare lists 69209 with bilateral indicator 1, so appending
50 brings extra reimbursement, but 69210 has bilateral indicator 2, which means appending 50 wont
increase reimbursement because its RVUs are already based on the procedure being performed as a
bilateral procedure. In fact, some experts suggest not appending 50 to 69210 at all for Medicare
because it risks triggering denials.

Dont Report 69209 for the Same Ear as 69210

Dont report both disimpaction codes on the same ear, CPT warns. If your provider starts out with
irrigation and then needs to switch to instrumentation to dig the wax out of that ear, report the code
that represents the higher intensity procedure.
Note also that the Correct Coding Initiative (CCI) bundles 69209 into 69210. Fortunately, if your provider
uses lavage to remove impacted cerumen from the right ear, then decides instrumentation would work
better in the left ear, you can unbundle the procedures to separate that CCI edit. To go back to our
example of lavage in the right ear with instrumentation in the left, you could report 69210-LT and
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

69209-RT for payers that accept the right and left side modifiers. If your payer nixes the right and left
modifiers, report 69210 followed by 69209-59.
By the way, both 69209 and 69210 are in version 22.0 of CCI as the column 1 procedure in more than
200 edit pairs, with bundled procedures ranging from wound repair to EEG monitoring.
Before considering reporting the two codes together, coders should first check to see if the payer
considers the codes to be unilateral or bilateral, to make sure you arent reporting work on the same ear
twice.

How About You?

Got any tips for dealing with reporting these tricky cerumen removal procedures? Let us know.

Fast Track Your Coding With Internal Medicine Coder!

With Internal Medicine Coder, you can find any code in a flash using flexible search options for CPT,
HCPCS, and ICD-10-CM. Easily and precisely pair your codes using CPTICD-10 CrossRef, CPT and
CMS allowed modifiers, and CPTHCPCS. You also get access to the expert advice of the Internal
Medicine Coding Alert, including its searchable archives. Many more customized features come with
Internal Medicine Coder Contact us today to learn more!

Enterprise Contact Person:

Name: Sam Nair
Title: Associate Director Enterprise Practice
Email: shyamn@codinginstitute.com
Direct: 704 303 8150

Desk: 866 228 9252, Ext: 4813

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com