Documentation for CPT code 69210 for removal of impacted cerumen must include: (1) a description of the impacted cerumen, rationale for removal, and time/effort required; (2) that cerumen met clinical criteria for impaction; and (3) that removal was performed under direct visualization using approved tools and that the patient was symptomatic. The procedure must be performed by a physician or NP/PA and documented with sufficient details of time and effort spent. Simple external earwax removal or asymptomatic/nurse-performed procedures do not qualify.

1. Documentation needs support the procedure 69210. Here are the guidelines.
The guidelines for the 69210 are is follows: Documentation Cerumen was impacted,
rationale for removing the impacted cerumen and the time, effort and equipment required
to remove the impacted cerumen.
CPT 69210 (Removal Impacted Cerumen) may be billed only if the following criteria are
met:
• Cerumen should meet clinical criteria of impaction
• Service performed under direct visualization using suction, a Cerumen spoon, or
delicate forceps
• Patient is symptomatic i.e. has symptoms such as partial hearing loss, itching,
tinnitus, otorrhea, sensation or fullness in the ear or pain
• Service is provided by physician or non physician practitioner (PA, NP)
• Documentation of service must support time and effort spent in performing
service.
The following do not support the billing of 69210
• Cerumen is not impacted
• Provider uses a simple instrument like a curette to remove simple external
earwax, this service is included in the EM service performed
• Cerumen removal via irrigation or lavage
• Patient is asymptomatic Service provided by nurse
• Service provided by other than physician or non physician provider
• Service not documented
I.E.
The right ear canal is completely obstructed with wax. With multiple attempts, I removed
about 60%, so I can see the upper part of his TM, which looks okay, too uncomfortable to
remove the rest of the wax. The left side had an 80% wax obstruction. With 3 passes of
curette, I was able to remove all of this. None of this relieved his symptoms, but the TM
again did not look inflamed. A 3+ brawny rhinitis