The removal of impacted cerumen (69209, 69210, G0268) is only medically necessary when reported with a diagnosis of impacted cerumen (ICD-10 codes H61. 2–H61.
Like CPT 69210, (removal of impacted cerumen requiring instrumentation, unilateral) 69209 requires that a physician or qualified healthcare professional make the decision to irrigate/lavage. However, unlike 69210, 69209 allows removal to be carried out by clinical staff.
ICD-10-CM Code for Impacted cerumen, right ear H61. 21.
ICD-10-CM Code for Impacted cerumen, left ear H61. 22.
You may not bill CPT code 69209 with CPT code 69210, “removal impacted cerumen requiring instrumentation, unilateral,” for the same ear. However, CPT codes 69209 and 69210 can be billed for the same encounter if impacted cerumen is removed from one ear using instrumentation and from the other ear using lavage.
A: The coder would report CPT code 69210 (removal impacted cerumen requiring instrumentation, unilateral) with modifier -50 (bilateral procedure) twice. Alternatively, the coder could report code 69210 twice with modifiers -LT (left side) and -RT (right side).
Cerumen impaction is defined as an accumulation of cerumen that causes symptoms or prevents assessment of the ear canal, tympanic membrane, or audiovestibular system; complete obstruction is not required.
earwaxDefinition of cerumen : earwax. Other Words from cerumen Example Sentences Learn More About cerumen.
CPT code 69210, Removal impacted cerumen, (separate procedure) one or both ears.
When you are using 69210 for ear wax impaction, it is appropriate to use an E/M code (with modifier -25) if the patient received a true evaluation and management for a separate problem (such as bronchitis or pharyngitis) or for complicating problems (such as dizziness or otitis media).
Code. Description. 69209. REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE, UNILATERAL.
SymptomsEarache.Feeling of fullness in the affected ear.Ringing or noises in the ear (tinnitus)Decreased hearing in the affected ear.Dizziness.Cough.