Q&A: CPT coding and billing for a bilateral cerumen removal

Q: A patient presents to the ED seeking treatment for impacted cerumen affecting both ear canals. How would you report a bilateral cerumen removal using CPT codes?

A: The coder would report CPT code 69210 (removal impacted cerumen requiring instrumentation, unilateral) with modifier -50 (bilateral procedure) twice. Alternatively, the coder could report code 69210 twice with modifiers -LT (left side) and -RT (right side). Because the CPT Manual describes the procedure as inherently unilateral, each instance of 69210 would be billed on a separate claim line with applicable modifiers.

Keep in mind: Although CPT guidelines clearly state that a surgical cerumen removal is a unilateral procedure, many payers have their own policies that contradict CPT guidance. Coders should check with payers to ensure that there are no policies in place that would prohibit them from billing cerumen removal as a bilateral procedure.

If the provider performs an audiologic function test in addition to the cerumen removal, coders should instead report the recently implemented HCPCS code G0268 (removal of impacted cerumen [one or both ears] by physician on same date of service as audiologic function testing) which is inherently bilateral.

Editor’s note: Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, CPAR, CPC, COC, and Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, answered this question during the HCPro webinar, “2019 Modifier Update: Review New NCCI Guidance.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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