When is it appropriate to report Current Procedural Terminology (CPT®) code 69210, removal of impacted cerumen?

Code 69210 (removal of impacted cerumen [separate procedure], one or both ears) is used when the physician, under direct visualization, removes impacted cerumen using, at a minimum, an otoscope and instruments such as wax curettes or an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angles). Medical record documentation must support that the cerumen was impacted and removed by the physician. Documentation must also include a description of what equipment and method was used to perform the procedure. A simple entry of “cerumen removed” is not sufficient and will not support reporting the separate service.

Removal of cerumen that is not impacted is included in an evaluation and management (E/M) code no matter how it is removed (ie, irrigation, lavage). Lavage or irrigation performed by a nurse...

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