By Stacie Norris, CCS-P, CPC
Impacted cerumen removal is a service that is performed regularly in the emergency department setting. In this article, we answer clinicians’ questions about how to report this service. There are 2 CPT codes that utilized for this service:
|Removal impacted cerumen using irrigation/lavage, unilateral
|Removal impacted cerumen requiring instrumentation, unilateral
Note that both CPT codes specify that the cerumen must be impacted to use these codes. For the removal of cerumen that is not impacted, the appropriate E/M code should be used to report the service. It is important that the clinician or APP document that the cerumen is impacted if this is the case so that the appropriate CPT code can be used to report the procedure.
If the clinician does diagnose impacted cerumen and removes the cerumen with irrigation/lavage, CPT code 69209, Removal impacted cerumen using irrigation/lavage, unilateral should be used(in addition to any E/M service that is performed).
If the clinician must use instrumentation such as a cerumen loop, curette, forceps or hook, CPT code 69210, Removal impacted cerumen requiring instrumentation, unilateral should be used (in addition to any E/M service that is performed).