CPT 69209 describes the removal of impacted ear wax from the ear using irrigation or lavage on one ear, with the option to use a small amount of antiseptic or antibiotic to prevent infection.
What Is CPT Code 69209?
CPT code 69209 describes the removal of impacted cerumen (ear wax) from the ear using irrigation or lavage, which is a procedure that involves using a syringe and catheter to instill water into the ear canal and then drain or suction it out to clear the cerumen.
The provider may also use a small amount of antiseptic or antibiotic to prevent infection.
69209 is performed unilaterally, meaning on only one ear. It is often used when a patient experiences symptoms such as fullness in the ears, ear pain, itching, or diminished hearing or blockage, and the provider cannot visualize the external auditory canal due to wax blockage.
The CPT book describes CPT code 69209 as: “Removal impacted cerumen using irrigation/lavage, unilateral.”
When a patient complains of fullness in the ears, ear pain, itching, or diminished hearing or blockage, the provider attempts to visualize the external auditory canal, the passage from the eardrum to the outer ear.
The wax blockage prevents visualization using microscopy, so the provider uses different techniques to remove the impaction from the patient’s external ear canal.
Suppose he chooses to irrigate or lavage the canal. In that case, he uses a syringe attached to a catheter to instill water, at body temperature, into the ear canal and drains or sucks the water back out with a needle to clear the cerumen.
The provider may also instill a small amount of antiseptic or antibiotic to prevent infection.
How To Use CPT 69209
CPT 69209 should not be reported with code CPT 69210 when both procedures are performed on the same ear.
If the provider performs the procedure on both ears, the payer’s guidelines should be followed for reporting a bilateral procedure, such as appending modifier 50 to CPT code 69209.
If the provider removes impacted cerumen from the ear, CPT code 69210 should be used.
CPT 99238 and CPT 99239 for hospital inpatient or observation discharge day management.
CPT 99304 until CPT 99316 for nursing facility services, or CPT 99341 until CPT 99350 for home or residence services.