Cerumen Removal

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December 17, 2015

Question:
I was in attendance at the “top ten coding issues” talk that you gave in Dallas at the AAOHNS annual meeting.  Great talk, Kim! We spoke regarding CPT 69210 after the session. I just want to confirm that use of magnification is not necessary for this code. My associates insist that 69210 requires using the operative microscope. I realize that simple lavage doesn’t qualify, but I use illumination and instruments and or suction. What is correct?

Answer:
Thank you for your kind words! You’re the second person this week to ask me the same question. Note the language for the code 69210 says, “Removal impacted cerumen requiring instrumentation, unilateral.” It does not say “requiring instrumentation and microscope.” The CPT vignette says that magnification is used but does not specify that a microscope must be used; therefore, use of an otoscope is acceptable for 69210 and a microscope is not required. That said, it is never appropriate to report 69990 with 69210 because 69990 is meant for microsurgical techniques/microdissection. Be sure you document the specific type of instrumentation used (e.g., curette, forcep, suction) for the cerumen impaction removal.

*This response is based on the best information available as of 12/17/15.