CODING Q&A Coding for Removal of Impacted Cerumen (69210) ■ DAVID STERN, MD, CPC Q . What is the correct use of CPT code 69210 (re- moval impacted cerumen [separate procedure], one or both ears)? - Question submitted by Kathy Partenheimer, Medical of Dubois In the July 2005 issue of CPT Assistant, the AMA clearly indicates that you should report 69210 only when the following two criteria are both met: Ⅲ “the patient had cerumen impaction” Ⅲ “the removal required physician work using at least an otoscope and instrumentation rather than simple lavage” [emphasis added]. A. Q . How does one determine that the cerumen is ac- tually impacted so that code 69210 may be used for removal of the cerumen? For the purpose of accurate coding, the AMA defines “impacted cerumen” in the July 2005 CPT Assistant as follows: Ⅲ “If any one or more of the following are present, ceru- men should be considered ‘impacted’ clinically: Ⅲ Visual considerations: Cerumen impairs exam of clin- ically significant portions of the external auditory canal, tympanic membrane, or middle ear condition. Ⅲ Qualitative considerations: Extremely hard, dry, irri- tative cerumen causing symptoms such as pain, itching, hearing loss, etc. Ⅲ Inflammatory considerations: Associated with foul odor, infection, or dermatitis. Ⅲ Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification A. David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at dstern@practicevelocity.com. w w w. j u c m . c o m and multiple instrumentations requiring physician skills.” Q . If the physician removes cerumen as part of the exam but the cerumen is not impacted, what code would be appropriate? A simplistic answer is that removing the wax is sim- ply included in the emergency and management (E/M) code. The actual situation, however, is not quite so straightforward. Since real-life medical coding is governed by multiple entities—including the AMA, CMS, and multiple private- sector payors—there are many areas of coding where con- flicting interpretations exist. Such ambiguity exists in the ap- plication of the code 69210. In this example, coders may make at least two inter- pretations: Ⅲ If you ask the physician if the wax was “impacted,” he or she may indicate that, because the cerumen was not stuck tightly and filling the entire ear canal, the wax was not “clinically impacted.” But be careful; you may be asking the wrong ques- tion. Before you give up too easily, ask the physician this question: “Why did you decide to remove the wax?” Chances are that the physician will tell you that the wax was getting in the way of performing an adequate oto- scopic exam of the ear. If so, then the wax actually does meet the strict AMA coding definition (listed above) for impacted cerumen. Since the removal of this “required physician work us- ing at least an otoscope and instrumentation,” the proce- dure could be billable with code 69210. Ⅲ In some situations, however, using this code according to the strict AMA definition may still not be appropriate. As CMS cautioned in the Federal Register of June 29, 2006 (page 37233), “It is our understanding that CPT code 69210 is to be used when there is a substantial amount A. JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | S e p t e m b e r 2 0 0 7 41