New coding breakthrough for cerumen removal
One of the new 2016 CPT codes that should see a great deal of use in pediatricians’ offices is the code that entails the removal of impacted cerumen using irrigation or lavage. Previously, when a patient had impacted cerumen, it had to be removed via instrumentation which, of course, was documented in the patient’s record and the CPT code would be 69210. If you chose to lavage the impacted cerumen – rather than mechanically removing it – you were certainly welcome to do so, but you would not be paid. Fortunately, that has now changed.
If the impacted cerumen was removed by lavage, the only correct code to use is 69209. If the procedure was done bilaterally, then the modifier 50 should be added to the second 69209. If you lavaged one ear and used instrumentation for the other ear, you should use 69209 as well as 69210; however, these two codes cannot be used together on the same ear. Use the correct codes and happy cerumen removal.
— Richard Lander, MD, FAAP, is a pediatrician for the Atlantic Medical Group, and clinical assistant professor of pediatrics at the University of Medicine and Dentistry of New Jersey in Newark, New Jersey. He is the chair of the AAP Private Payer Advocacy Advisory Committee and a member of the Infectious Diseases in Children Editorial Board.