69209
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
$17.03
Non-Facility
$17.03
Documentation Required
- The patient medical record must include the ordering provider's assessment related to the patient's complaint for that visit.
- Medical records must contain relevant medical history and results of pertinent tests/procedures; for diagnostic tests report the result if known, otherwise report the symptoms prompting the test.
- Office visit records and operative reports must be signed and dated; all services ordered or rendered to Medicare beneficiaries must be signed.
- When an ABN is used for anticipated denials, the beneficiary should sign Form CMS-R-131 to accept financial responsibility; for Part A MAC claims, occurrence code 32 and the date of the ABN are required.
Key Coverage Criteria
- Medically necessary removal of impacted cerumen requiring a physician's skill is covered when removal by a non-physician poses an unacceptable risk of complications such as tympanic membrane perforation.
- Removal requiring physician skill is indicated when the tympanic membrane cannot be observed (e.g., total occlusion or impaction).
- Removal requiring physician skill is indicated for overt medical contraindications such as anatomical abnormalities, prior surgical modifications of the ear canal, or presence of infection risk that increase complication risk.
- Removal requiring physician skill is indicated when medical conditions pose undue risk of excessive bleeding (e.g., patient on anticoagulants).
- Removal requiring physician skill is indicated when cerumen cannot be removed safely without undue risk of abrasion, laceration, or tympanic membrane perforation.
- Payment is allowed for medically necessary removal of symptomatic impacted cerumen (i.e., when symptoms such as hearing loss, pain, itching, cough, dizziness, vertigo, or tinnitus are present).
2 Active Policies
A56454 — Billing and Coding: Cerumen (Earwax) Removal
L33945 — Cerumen (Earwax) Removal
Related Codes
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