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2014 Changes for Impacted Cerumen

AMA has clarified the CPT Code for impacted cerumen for 2014.  CPT 69210 will now be reported as a “unilateral” code.  Another noteworthy revision is that, physicians must use some type of instrumentation and may not remove ear wax solely by irrigation or lavage.  This follows the guidance given to AMA from American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) many years ago.
The new 2014 CPT descriptor for 69210 is as follows:
69210, Removal impacted cerumen requiring instrumentation, unilateral
Payers typically will not cover simple, non-impacted earwax removal.  This work is included in the E/M service; therefore CPT 69210 should not be used.  If earwax is removed by irrigation or lavage only an E/M should be billed.
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, ordermatitis; or
·         obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician skills.
Instruments are utilized to remove the impacted earwaxare 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).   Documentation should not only support the use of the instruments, but also the need of their use to provide the service.
Unilateral Procedure
As the descriptor for code 69210, indicates the code is to be unilateral.  A parenthetical also has been added stating; “For bilateral impacted cerumen removal, report code 69210 with modifier 50, Bilateral Procedure, appended.
Requirements for reporting 69210 with an E/M on the same DOS
To reporting an E/M visit and cerumen removal on the same date of service (DOS), all the following criteria’s must be met and be clearly documented within the patient’s medical record:
  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.
Modifier -25
When all of the above conditions are met, a medical necessary E&M and 69210 may be reported together.  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.  Finally, it is important to include the applicable ICD-9/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.  Instead use CPT code 92504,Binocular microscopy (separate diagnostic procedure).
Audiologists Reporting 69210
Finally, Medicare will not cover cerumen removal performed by an audiologist. For Medicare patients, the physician should only bill 69210 when removing cerumen on the same day as audiology testing.  Some carriers might require the HCPCS code G0268.  Independent audiologists cannot bill 69210.
CPT® is registered trademark of the American Medical Association.

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