How To Use CPT Code 69210

CPT 69210 refers to the removal of impacted cerumen requiring instrumentation, unilateral. This article will cover the description, procedure, qualifying circumstances, when to use the code, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 69210 procedures.

1. What is CPT 69210?

CPT 69210 is a medical billing code used to describe the removal of impacted cerumen (earwax) requiring instrumentation in a unilateral (one-sided) procedure. This code is utilized by medical coders and billers to accurately document and bill for this specific procedure when performed by healthcare providers.

2. 69210 CPT code description

The official description of CPT code 69210 is: “Removal impacted cerumen requiring instrumentation, unilateral.”

3. Procedure

The 69210 CPT code procedure involves the following steps:

1. The healthcare provider examines the patient’s ear and identifies the presence of impacted cerumen.
2. The provider uses an instrument such as a curette, vacuum evacuation, or forceps to remove the entrapped wax from the patient’s external auditory canal.
3. The procedure is performed on one ear only (unilateral).
4. Once the impacted cerumen is removed, the provider re-examines the ear to ensure proper clearance of the wax.

4. Qualifying circumstances

Patients eligible to receive CPT code 69210 services are those who present with symptoms such as ear fullness, pain, itching, diminished hearing, or blockage due to impacted cerumen. The healthcare provider must determine that the cerumen is impacted and requires instrumentation for removal. If the cerumen is not impacted, an evaluation and management (E/M) code should be used instead.

5. When to use CPT code 69210

It is appropriate to bill the 69210 CPT code when a healthcare provider performs a unilateral procedure to remove impacted cerumen requiring instrumentation. This code should not be used for bilateral procedures, cerumen removal without instrumentation, or when the cerumen is not impacted.

6. Documentation requirements

To support a claim for CPT 69210, the following information should be documented:

• Patient’s presenting symptoms and history
• Physical examination findings, including the presence of impacted cerumen
• Details of the procedure, including the type of instrumentation used and the ear treated
• Outcome of the procedure, such as the amount of cerumen removed and any complications

7. Billing guidelines

When billing for CPT code 69210, keep in mind the following guidelines and rules:

• Code 69210 is a unilateral procedure. If the provider removes impacted cerumen from both ears, follow payer guidelines for reporting a bilateral procedure, such as appending modifier 50 to the code.
• Check the payer’s bilateral indicator for the code, as some payers will not increase reimbursement for a bilateral 69210 service.
• Do not report 69210 in conjunction with 69209 when performed on the same ear.
• For removal of impacted cerumen achieved with irrigation and/or lavage but without instrumentation, use 69209.
• For cerumen removal that is not impacted, see E/M service codes.

8. Historical information

CPT 69210 was added to the Current Procedural Terminology system on January 1, 1990. There have been changes to the code’s descriptor over the years, with the most recent change occurring on January 1, 2014.

9. Similar codes to CPT 69210

Five similar codes to CPT 69210 and how they differentiate are:

• CPT 69209: This code is used for impacted cerumen removal using irrigation or lavage, without instrumentation.
• CPT 69200: This code is for the removal of a foreign body from the external auditory canal, without general anesthesia.
• CPT 69220: This code is for the removal of a foreign body from the middle ear, without general anesthesia.
• CPT 92504: This code is for binocular microscopy of the ear, which may be performed before or after cerumen removal.
• G0268: This code is used for Medicare claims when the physician removes impacted ear wax on the same day as an audiologist conducts audiologic function testing.

10. Examples

Here are 10 detailed examples of CPT code 69210 procedures:

1. A patient presents with ear pain and diminished hearing in the left ear. The provider examines the ear and finds impacted cerumen. The provider uses a curette to remove the impacted cerumen from the left ear.
2. A patient complains of fullness and itching in the right ear. The provider identifies impacted cerumen and uses vacuum evacuation to remove it from the right ear.
3. A patient experiences blockage in the left ear. The provider discovers impacted cerumen and uses forceps to remove it from the left external auditory canal.
4. A patient with a history of recurrent impacted cerumen presents with diminished hearing in the right ear. The provider removes the impacted cerumen using a curette.
5. A patient complains of ear pain and fullness in the left ear. The provider finds impacted cerumen and uses vacuum evacuation to remove it from the left ear.
6. A patient with a history of earwax impaction presents with itching and blockage in the right ear. The provider removes the impacted cerumen using forceps.
7. A patient experiences ear pain and diminished hearing in the left ear. The provider identifies impacted cerumen and uses a curette to remove it from the left ear.
8. A patient complains of fullness and itching in the right ear. The provider finds impacted cerumen and uses vacuum evacuation to remove it from the right ear.
9. A patient with a history of recurrent impacted cerumen presents with blockage in the left ear. The provider removes the impacted cerumen using forceps.
10. A patient experiences ear pain and fullness in the left ear. The provider identifies impacted cerumen and uses a curette to remove it from the left external auditory canal.