How To Use CPT Code 69000

CPT 69000 describes the procedure for drainage of an abscess or hematoma in the external ear. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69000?

CPT 69000 can be used to describe the procedure performed by a healthcare provider to drain an abscess or hematoma in the external ear. This code is used when the provider makes a simple incision and drains the pus or blood from the affected area to relieve pain and prevent further infection.

2. Official Description

The official description of CPT code 69000 is: ‘Drainage external ear, abscess or hematoma; simple.’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. The provider makes a simple incision in the external ear to access the abscess or hematoma.
3. Purulent material or blood is drained from the abscess or hematoma.
4. The provider observes the patient for a brief period and releases them.

4. Qualifying circumstances

CPT 69000 is performed when a patient has a simple abscess or hematoma in the external ear that requires drainage. The procedure is done to relieve pain and prevent further infection. The patient must be appropriately prepped and anesthetized before the procedure.

5. When to use CPT code 69000

CPT code 69000 should be used when a healthcare provider performs a simple incision and drainage of an abscess or hematoma in the external ear. It is important to note that this code is specifically for simple cases and should not be used for more complicated abscesses or hematomas.

6. Documentation requirements

To support a claim for CPT 69000, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for drainage of the abscess or hematoma
• Details of the procedure, including the incision and drainage process
• Any additional procedures performed, such as wick insertion
• Observation period and any post-procedure instructions
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 69000, ensure that the procedure performed is a simple incision and drainage of an abscess or hematoma in the external ear. It is important to note that wick insertion is bundled into the drainage code if performed during the same procedure. CPT code 69005 should be used for more complicated abscesses or hematomas in the external ear, and CPT code 69020 is used for abscesses within the external ear canal.

8. Historical information

CPT 69000 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A healthcare provider performs a simple incision and drainage of an abscess in the external ear to relieve pain and prevent further infection.
2. A patient presents with a hematoma in the external ear, and the provider performs a simple incision and drainage to remove the blood and alleviate discomfort.
3. During an examination, a healthcare provider identifies an abscess in the external ear and performs a simple incision and drainage to treat the infection.
4. A patient with a history of recurrent abscesses in the external ear undergoes a simple incision and drainage procedure to alleviate symptoms and prevent future infections.
5. A healthcare provider performs a simple incision and drainage of a hematoma in the external ear to reduce swelling and promote healing.
6. After assessing a patient with an abscess in the external ear, a provider performs a simple incision and drainage to remove the pus and improve the patient’s condition.
7. A patient presents with a painful hematoma in the external ear, and the healthcare provider performs a simple incision and drainage to relieve discomfort and prevent complications.
8. During a routine examination, a healthcare provider identifies an abscess in the external ear and performs a simple incision and drainage to treat the infection and promote healing.
9. A patient with a history of trauma to the external ear develops a hematoma, and the provider performs a simple incision and drainage to alleviate pain and prevent complications.
10. A healthcare provider performs a simple incision and drainage of an abscess in the external ear to relieve symptoms and prevent the spread of infection.