March 2016 page 11
Surgery: Auditory System
Question: How is removal of cerumen reported?
Answer: For impacted cerumen removal that requires instrumentation (eg, cerumen loop/curette, forceps, suction, hook), report code 69210, Removal impacted cerumen requiring instrumentation, unilateral. For the removal of impacted cerumen using irrigation without instrumentation, report code 69209, Removal impacted cerumen using irrigation/lavage, unilateral. For the removal of cerumen that is not impacted, report the appropriate evaluation and management (E/M) service code (eg, 99201-99215, 99221-99223).
Surgery: Auditory System (Q&A) (March 2016). CPT® Assistant. 2016; March 2016 page 11
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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 March 2016 CPT Assistant Q&A article focuses on coding for cerumen removal in the auditory system. It is useful for coders, billers, and clinical documentation staff who need a high-level understanding of the reporting categories discussed and the general circumstances covered by the guidance.
Why This Topic Matters
Cerumen removal is a common outpatient service, and proper reporting depends on the general type of service performed and the documentation captured. This article helps readers understand the scope of the CPT guidance discussed for this topic.
Article Sections
March 2016 page 11
A short introductory page reference for the CPT Assistant Q&A content that follows.
What You Will Learn
The general CPT reporting categories discussed for cerumen removal.
How the article frames different approaches to reporting auditory-system cerumen services.
What types of supporting code references are mentioned in the guidance.
The kinds of audience members who would use this coding topic for reference.
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