Removal of Impacted Cerumen (January 2016)

January 2016 pages 7-8 Removal of Impacted Cerumen In the Current Procedural Terminology (CPT ® ) 2016 code set, code 69209 was added to the Auditory System subsection to report the removal of impacted cerumen (earwax) using irrigation or lavage. Impacted cerumen was defined in CPT Assistant October 2013, page 14, as having any of the following: Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition. Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc. Inflammatory considerations: Associated with foul odor...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This January 2016 CPT Assistant article explains updated guidance for impacted cerumen removal in the CPT 2016 code set. It is relevant to otolaryngology, primary care, and billing/coding staff who need to understand the general scope of the revision, related parenthetical notes, bilateral reporting, and when evaluation and management services may be considered in the context of cerumen removal.

Why This Topic Matters

The article helps coders and clinicians recognize how the CPT code set distinguishes approaches to impacted cerumen removal and how related reporting guidance was updated for 2016. It also provides context for service selection and documentation expectations without replacing the full premium discussion.

Article Sections

  1. Removal of Impacted Cerumen

    Introduces the topic and summarizes the 2016 CPT update affecting reporting of cerumen removal services.

  2. Table 1. Impacted Cerumen Removal Comparison

    Presents a side-by-side comparison of the two reportable approaches and their general reporting context.

  3. Coding Tip

    Highlights additional reporting guidance and how cerumen removal relates to evaluation and management services.

  4. Clinical Example (69209)

    Provides an illustrative scenario related to the irrigation/lavage approach.

  5. Description of Procedure (69209)

    Describes the general procedural workflow associated with the irrigation/lavage example.

  6. Clinical Example (69210)

    Provides an illustrative scenario related to the instrumented approach.

  7. Description of Procedure (69210)

    Describes the general procedural workflow associated with the instrumented example.

What You Will Learn

  • How the CPT 2016 update addressed impacted cerumen removal
  • The general distinction between the two cerumen removal approaches discussed in the article
  • What kinds of parenthetical notes and bilateral reporting guidance were added
  • When the article indicates evaluation and management services may be relevant
  • The types of clinical examples and procedural descriptions included for reference

Who Should Read This

  • Medical coders
  • Billing staff
  • Physicians
  • Other qualified health care professionals
  • Primary care practices
  • Otolaryngology practices

Codes Discussed

Code Ranges Discussed

Modifiers Discussed


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