If your PCP is billing 69210 (Removal impacted cerumen [separate procedure], one or both ears), you can bet the auditors will be checking your documentation. If you follow these 3 tips, you can be sure you’re using the code correctly.
1. Check If Wax Is Impacted
The first thing that you need to do is to fully understand the definition of impacted cerumen (384.0). “Remember that 69210 is actually a surgical procedure,” urges Kris Cuddy, CPC, CIMC, independent consultant in DeWitt, Minn.
The American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) says that if any one or more of the following are present, cerumen is considered clinically “impacted”:
• 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...
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