Background: Coding and billing for the treatment of cerumen impaction via lavage or washing and irrigating has long been a confusing issue for providers. It is a long-standing opinion by the American Medical Association (AMA) that the intention of CPT code 69210 is for use when the provider uses instruments rather than lavage. The AMA and certain MACs have repeatedly published guidelines and put in claim processing edits addressing this issue. In CPT Assistant, July, 2005, the AMA stated that the use of this code is “by a physician using at a minimum an otoscope and instruments.”
On January 1, 2009, the actual CPT description changed to reflect both the AMA and the Centers for Medicare & Medicaid Services’ (CMS) intention. Specifically it went from: “Removal impacted cerumen” to “Removal of impacted cerumen, requiring instrumentation.” Providers were again instructed to bill lavage as part of the examination portion of Evaluation and Management. In October 2013, the AMA published a clarifying CPT Assistant article relating that cerumen impaction treated with lavage or washing was not appropriate to report with CPT Code 69210 (see Exhibit I). In January, 2016, the AMA and CMS published a new CPT code reflecting the work for ear lavage that is now separately reportable from an Evaluation and Management Service.
Direction to NEXTGEN RCM: When a claim is denied for cerumen impaction removal (CPT code 69210), please perform the following procedures:
| Step | Description | Instructions / Comments |
| 1 | Examine the body of the medical record for documentation of the diagnosis & assure that the appropriate diagnosis is mapped to the cerumen code. | Look for appropriate assignment of ICD code for impaction:ICD9:
380.4 Impacted cerumen ICD10 H61.20 Impacted cerumen, unspecified ear H61.21 Impacted cerumen, right ear H61.22 Impacted cerumen, left ear H61.23 Impacted cerumen, bilateral
** IF impaction is NOT documented, this is NOT separately reportable:
If impaction is NOT documented: Query the provider to clarify impaction. Query the provider in NG email, note the encounter and email the provider at: munroparents@hotmail.com |
| 2 | Examine the body of the medical record for documentation of cerumen removal technique.
See Table 1 Below (from Exhibit I) |
Look for notation of use of instrumentation (forceps, suction, vs. washing / lavage. Look for notation of result. Typically “good result” – or “ear clear”, or “tympanic membrane visible” w/ documentation of external ear canal state.
IF instrumentation is used – use CPT code: 69210 IF lavage is used – use CPT code: 69209 |
| 3 | Examine the body of the medical record for documentation of laterality and note payer.
*Appropriately reporting bilateral procedures depends upon the technique (CPT Code) & the payer. |
IF payer is MEDICARE and CPT code is 69210:If bilateral: only bill ONE unit & NO 50 modifier; it’s inherently bilateral for Medicare.
If unilateral: bill one line item w/ directional modifier LT/RT.
IF payer is COMMERCIAL and CPT code is 69210: If bilateral – may bill two line items w/ modifiers RT/LT or one line item w/ 50 modifier. Will be payer dependent. If unilateral: bill one line item w/ directional modifier LT/RT.
IF payer is MEDICARE or COMMERCIAL and CPT code is 69209: If bilateral: MEDICARE: use 1 line item w/ unit of 1, Modifier 50 If bilateral: COMMERCIAL – try Medicare method first, but may need to bill on two line items w/ directional modifiers LT/RT.
If unilateral: append directional modifier LT/RT. |
| 4 | Determine if code / claim needs to be corrected or appealed. | If instrumentation – leave CPT code 69210, appeal with documentation. If lavage – change CPT to 69209 and submit corrected claim. |
| 5 | Determine if E/M is also billed & if modifier -25 is appropriate to append. | If E/M code is billed w/ either CPT 69210 or 69209:
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Additional POST-ICD-10 IMPLEMENTATION Direction: This policy has been written AFTER ICD-10 implementation. There is presently no Coverage Determination in Michigan. If an LCD is authored in this jurisdiction, (there is one in others) the practice and NextGen RCM Services will work together to review and revise the policy pursuant to any published guidelines.
Statement of Responsibility: As the providers of medical care, we understand we are solely responsible for all coding activities and are prepared to supply supporting documentation corresponding to submitted claims when requested by payers. This directive may be rescinded at any time. If material payer directive(s), CPT Assistant(s), ICD or HCPCS coding clinics are published that would alter this directive, we will work diligently to change the directive in a timely manner.