CPT® Code: 69209
Description:
CPT® 69209 covers the removal of impacted cerumen (earwax) from the external auditory canal using instrumentation or irrigation. This procedure is performed when earwax buildup causes symptoms such as hearing loss, pain, fullness, or tinnitus, or when it obstructs the visualization of the ear canal for diagnostic purposes.
When to Use:
- Patients present with symptomatic cerumen impaction, including hearing difficulties, ear discomfort, or recurrent infections.
- Prior attempts at home removal (ear drops or irrigation) have been ineffective.
- Cerumen obstructs diagnostic procedures, such as otoscopic examinations or tympanometry.
Requirements for Billing:
- The procedure must be performed by a licensed healthcare provider.
- Documentation must include clinical indication, the ear(s) treated, method used (instrumentation vs. irrigation), and patient tolerance.
- Each ear is billed separately if both are treated during the same visit.
Includes:
- Use of curettes, suction, or irrigation to remove cerumen.
- Patient counseling on ear hygiene and prevention of recurrence.
- Documentation of findings, technique, and post-procedure status in the patient record.
OptiMantra Integration:
With OptiMantra, clinics can streamline documentation of cerumen removal procedures. Providers can quickly log each ear treated, record techniques used, and integrate findings into the patient’s chart for accurate billing and follow-up care. OptiMantra’s EMR ensures compliant documentation and helps practices maintain efficient workflows while improving patient outcomes.
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