November 5, 2015

Question:  

I just wanted to verify the guidelines for billing cerumen removal (69210). Before, it needed to state that the cerumen was “impacted” to be able to bill CPT 69210. I was just told that guideline has changed and that anything that goes in the body (I’m thinking like a curette to remove cerumen), even if it is not impacted, is now billable. Is this correct?

Answer:

That is incorrect information – the guideline has not changed in that regard. The cerumen must be impacted to report 69210 (Removal impacted cerumen requiring instrumentation, unilateral). What did change a few years ago is the added requirement that instrumentation must be used to remove the impacted cerumen. So, there must be documentation of using a curette, forceps, suction, etc. in the procedure note. Click here for one hour webinar on Resolving the Cerumen Coding Chaos!

*This response is based on the best information available as of 11/05/15.