Updated guidance (7/18/19): What happens when an attempt at ear wax removal doesn't clear any wax? Should you report 69209 or 69210? Find out here.
Physicians will have another way to report removing ear wax in 2016 now that surgical code 69209 (Removal impacted cerumen irrigation/lavage, unilateral) joins higher level 69210 (Removal impacted cerumen requiring instrumentation, unilateral) in the auditory system section.
Report 69210 when you use instrumentation to clear impacted cerumen; otherwise, report 96209 for the less-intensive “continuous low pressure flow of liquid (e.g., saline) to gently loosen impacted cerumen and flush it out,” states the updated CPT Changes codebook.
To use the new code, ensure you’re dealing with impacted ear wax, noted Richard Waguespack, M.D., AMA CPT advisory committee member and conference speaker during the AMA’s CPT® and RBRVS 2016 Annual Symposium that took place Nov. 18 to 20 in Chicago.
Impaction means the cerumen is hard and dry and may block the provider’s ear exam, explains Waguespack. So be sure providers note the characteristics of impaction in their notes.
When there’s no impaction, don’t use the 69000 series codes. “All non-impacted cerumen should be reported with an E/M,” advises Silvia. Also, you “cannot bill both [69209 and 69210] at the same time for the same ear,” she says.
Also, follow the same modifier usage as 69210 — that is, use modifier 50 (Bilateral procedure) to report a bilateral procedure with 69209.