In the Current Procedural Terminology (CPT®) 2016 code
set, code 69209 was added to the Auditory System subsection to report the removal of impacted cerumen (earwax)
using irrigation or lavage. Impacted cerumen was defined
in CPT Assistant October 2013, page 14, as having any of
the following:

Visual considerations

Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.

Inflammatory considerations

Associated with foul odor, infection, or dermatitis.

Qualitative considerations

Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc

Quantitative considerations

Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.

Code 69209	Code 69210
Uses irrigation or lavage	Uses instrumentation (eg, curettes, hooks, forceps, suction)
May be performed by trained office personnel under the supervision of the physician or other qualified health care professional	Requires significant physician or other qualified health care professional work
Cannot be reported with code 69210 on the same day for the same ear	Cannot be reported with code 69209 on the same day for the same ear
Report the appropriate E/M code if cerumen is not impacted	Report the appropriate E/M code if cerumen is not impacted
For a bilateral procedure, append modifier 50	For a bilateral procedure, append modifier 50

Code 69209 is reported when irrigation and/or lavage is used to remove impacted cerumen. This method uses a continuous flow of liquid (eg, saline, water) to loosen impacted cerumen and flush it out with or without the use of a cerumen softening agent. (See Figure 1.) Although direct physician work is not required, the removal of cerumen by irrigation or lavage usually takes longer to perform and may require additional staff time and equipment.

Code 69210 is reported when an instrumented approach is used for cerumen removal. The procedure must be performed by a physician or other qualified health care professional using instrumentation such as curettes, hooks, forceps, and suction to remove the impacted earwax. Only one code (69209 or 69210) may be reported for the primary service provided on the same day on the same ear. Modifier 50, Bilateral Procedure, should be appended if either one of the cerumen removal procedures is performed on both ears.

Codes 69209 and 69210 should not be reported together when both services are provided on the same day on the same ear.

The appropriate evaluation and management (E/M) code based upon category and site of service (eg, office or other outpatient, hospital care, nursing facility services) should be reported when nonimpacted cerumen is removed.

An E/M code may be reported if there is a separate and distinct service performed at the same session.

Description of Procedure (69209)

The equipment, supplies, and patient are prepared. A special syringe tip adapter for ear irrigation or an adapter with butterfly tubing is placed at the end of a syringe containing lukewarm water or saline. A large sheet or drape is placed over the patient’s clothing to prevent it from getting wet. The tip of the adapter is placed inside the patient’s ear, and the water is pushed in gently to extrude impacted cerumen. A basin is held on the patient’s shoulder to catch the water. When the syringe is emptied, the adapter is removed and more water is drawn in from a bowl. This step is repeated until cerumen is removed as proven by examination of the ear canal. The operator (nurse or physician) intermittently checks with an otoscope to see how much cerumen is still left and its location to try to direct appropriately the stream of water. If it is apparent that cerumen cannot be dislodged, a cerumenolytic agent to coat the cerumen to reduce surface tension is instilled in the patient’s ear before trying again. The patient lies on his side for several minutes with the affected ear up as irrigation proceeds. The procedure ends when the cerumen impaction is removed or the physician and patient or caregiver agree that another approach is required.

Description of Procedure (69210)

Examine the pinna and external auditory canal. Grasp the pinna and expose and open the external auditory canal. Position the instrument of magnification. Remove cerumen using a variety of instrumentation including cerumen curettes, spoons, suctions, and microforceps. Occasionally, concurrent irrigations are required along with suction. Take care not to injure the external auditory canal or tympanic membrane. After removal is completed, examine the external auditory canal and tympanic membranes, note status, and grossly assess hearing

Removal of Impacted Cerumen

Visual considerations

Inflammatory considerations

Qualitative considerations

Quantitative considerations

Table 1. Impacted Cerumen Removal Comparison

Figure 1. Irrigating Water Into Ear With Syringe (Code 69209)

Coding Tip

Clinical Example (69209)

Clinical Example (69210)

Description of Procedure (69209)

Description of Procedure (69210)

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