Appropriate Coding and Billing of Cerumen Removal

Author: Kim Cavitt, Au.D.

Cerumen removal by an audiologist is affected by several factors such as the payer, the extent of the cerumen present in the ear canal, and whether or not cerumen removal is within the scope of practice of the audiologist providing the service. Audiologists can determine if cerumen removal is within their scope of practice by reviewing their state audiology licensure laws and rules.

Medicare does not cover treatment services, such as removal of impacted or non-impacted cerumen, when provided by a licensed audiologist practicing within their scope of practice.

“Cerumen impaction”, as defined by the CPT Assistant (CPT Assistant, July 2005) must meet one or more of the following conditions to be considered “impacted”. They include:
  • “Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane or middle ear condition;
  • Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.;
  • Associated with foul odor, infection or dermatitis;
  • Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations”
Removal of impacted cerumen requires visualization with an otoscope, head loupes, or operating microscope and the use of specialized tools such as curettes, forceps, lavage, and/or suction for proper removal. The CPT Assistant article further states, “removing wax that is not impacted does not warrant the reporting of CPT code 69210 [Removal of impacted cerumen (separate procedure), 1 or both ears].” Documentation of cerumen removal should include the time, effort, method(s) and equipment to provide the service.

Medicare does not recognize, and therefore does not reimburse, licensed audiologists as treatment providers, despite what may be in their scope of practice as defined by state audiology licensure laws. For services categorized as treatment, such as impacted cerumen removal as described above, an audiologist can bill the Medicare beneficiary privately for the removal of the impacted cerumen. The use of an Advanced Beneficiary Notice of Noncoverage (ABN) would be voluntary in this scenario as coverage is statutorily excluded. If the Medicare beneficiary requests that you submit a claim to Medicare for removal of impacted cerumen, it would be appropriate to use CPT code 69210 (removal of impacted cerumen) and the appropriate modifier(s) (i.e., -GX, Item or service expected to be denied because it is not a covered service—ABN signed and/or –GY, Item or service statutorily excluded or does not meet the definition of a Medicare benefit).

For Medicare beneficiaries, the removal of cerumen that is not impacted as defined above is considered a part of the audiologic test procedure and should not be billed separately. In these cases, the otoscopic inspection reveals that cerumen is present in the ear canal, but that this cerumen is not truly impacted. The entire tympanic membrane or a portion of the tympanic membrane is visible. As a result, removal of this type of cerumen requires visualization with magnification and use of swabs, curettes, irrigation, suction and/or a softening agent for proper removal. Cerumen must be removed prior to audiologic testing so as to not negatively impact the test results. If cerumen is not impacted, it does not meet the requirements of the use of 69210 (removal of impacted cerumen). As a result, the removal of this cerumen would be inclusive to the audiologic testing and should not be billed separately to the beneficiary.

For non-impacted cerumen that needs removal, (e.g. when insert earphones will be utilized, to manage hearing aid feedback or when a deep fitting aid is being utilized), CPT code 92700, unlisted otorhinolargyngological service or procedure, should be utilized. Do not use 69210 for non-impacted cerumen removal, as noted in the CPT Assistant (which applies to all payors). If the patient is a Medicare beneficiary, you may offer them a voluntary ABN, using the –GX and/or-GY modifiers. In any instance of cerumen removal, your documentation (including, potentially, a copy of the video otoscope photograph) should clearly describe the reason for the visit, type and location of the cerumen within the canal, whether it is impacted or non-impacted and the removal method(s) utilized.

As the guidance regarding the use of 69210 is from the CPT Assistant and not Medicare, the same restrictions on its use applies to all payers. We strongly advise that you consult your third-party agreements and payers regarding coverage, or the lack thereof, of removal of impacted or non-impacted cerumen within their plans. Also, it is important to note, when billing for removal of impacted cerumen (69210), the claim should included the ICD-9 diagnosis code of 380.4 (Impacted cerumen).

In summary:

Cerumen Removal-Medicare Beneficiary
Clinical Situation Impacted Cerumen Non-Impacted Cerumen
Diagnostic test procedure performed on same date of service as the cerumen removal The Medicare beneficiary could be billed privately for the cerumen removal as 69210 (Removal of impacted cerumen) is statutorily excluded from coverage if performed by an audiologist; ABN use is voluntary The cerumen removal is incidental to and inclusive of the diagnostic testing and thus cannot be billed to either Medicare or the beneficiary.
No diagnostic testing is performed on the same date of service as the cerumen removal The Medicare beneficiary could be billed privately for the cerumen removal as 69210 (Removal of impacted cerumen) is statutorily excluded from coverage if performed by an audiologist; ABN use is voluntary; if a beneficiary requests that the claim be submitted to Medicare, code 69210 should be used and a –GX and/or –GY modifier added The Medicare beneficiary could be billed privately for the cerumen removal as cerumen removal is a form of treatment and audiologists are statutorily excluded from coverage of treatment by Medicare; ABN use is voluntary; if a beneficiary requests that the claim be submitted to Medicare, code 92700 should be used and documentation should be submitted with the claim
Cerumen Removal-Non Medicare Patient
Clinical Situation Impacted Cerumen Non-Impacted Cerumen
Diagnostic test procedure performed on same date of service as the cerumen removal Please consult your third-party payer policy manual, payer agreement and fee schedule for specific guidance; if a patient requests that the claim be submitted to their payer, code 69210 should be used Please consult your third-party payer policy manual, payer agreement and fee schedule for specific guidance; if a patient requests that the claim be submitted to their payer, code 92700 should be used and documentation should be submitted with the claim
No diagnostic testing is performed on the same date of service as the cerumen removal Please consult your third-party payer policy manual, payer agreement and fee schedule for specific guidance; if a patient requests that the claim be submitted to their payer, code 69210 should be used Please consult your third-party payer policy manual, payer agreement and fee schedule for specific guidance; if a patient requests that the claim be submitted to their payer, code 92700 should be used and documentation should be submitted with the claim


Author’s Note: The author would like to thank Lisa Satterfield, MA from the American Speech-Language-Hearing Association for her contributions to this guidance document.She would also like to thank Rita Chaiken, Au.D. for her editorial guidance throughout the creation of this document.    
References:
CPT Assistant. July 2005. American Medical Association.

Coding for Cerumen Removal; American Academy of Otolaryngology-Head and Neck Surgery (2010), http://www.entnet.org/Practice/Coding-for-Cerumen-Removal.cfm.


Kim Cavitt, Au.D. was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the Board of the Academy of Doctors of Audiology and the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.