Cerumen Removal

There are two codes for cerumen removal

69209  Removal impacted cerumen using irrigation/lavage, unilateral
69210  Removal impacted cerumen (separate procedure), 1 or both ears

Key points

• Document the medical necessity for cerumen removal (patient’s complaints, diminished hearing, physical exam)
• Document the results: was the procedure successful?
• Whether it is a clinical staff member or practitioner who performs the service, be sure to document the service
• Cerumen removal is covered if there are visual considerations (impacts exam) qualitative considerations, hard, dry, irritative was causing pain, hearing loss or itching, inflammatory considerations, associated with odor, infection or dermatitis or quantitative considerations, obstructive or copious.
• Use 69209 for lavage. This can be done by a staff member.
• For 69210, the physician/NP/PA must remove the wax with instrumentation
• For a planned procedure, “I’m here to have the wax removed,” do not bill an E/M