Who performs cerumen removal?
Audiologists and otolaryngologists (ear, nose and throat doctors, or ENTs) are both trained in cerumen management; cerumen removal is within the scope of practice of each specialty.
Audiologists are state-licensed health care professionals defined in the Medicare statute (see 42 U.S.C. § 1395x(ll)) who are able to file claims with Medicare for diagnostic services only (see CMS Program Memorandum AB-02-080 (PDF)).
How does Medicare cover cerumen removal?
Cerumen removal is included in the value for every audiometric and vestibular function test. Removing wax that is not impacted does not warrant the reporting of CPT code 69210. Removal of non-impacted cerumen is captured in the office visit, or an evaluation & management code. Just as with cerumen removal, the office visit is a non-covered Medicare service when performed by an audiologist.
Removal of impacted cerumen is reported with CPT code 69210. Chart documentation should include the time, effort, and equipment necessary to provide the service. Because cerumen removal is considered a surgical procedure, it is a non-covered Medicare procedure when performed by an audiologist. (Medicare Carriers Manual § 2070.3.)
Note: A major determining factor in the reporting of CPT code 69210 is understanding what is considered “impacted cerumen.” The AAO-HNS defines it as follows:
If any one or more of the following are present, cerumen should be considered “impacted” clinically.
- Visual considerations: Cerumen impairs exam of clinically significant portion of the external auditory canal, tympanic membrane, or middle ear condition.
- Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.
- Inflammatory considerations: Associated with foul odor, infection, or dermatitis.
- Qualitative considerations: Obstructive, copious amounts that cannot be removed without magnification and multiple instrumentations requiring physician skills.
The Bottom Line:
- Medicare covers cerumen removal if billed by a physician, but not if billed by an audiologist. Medicare only covers diagnostic testing performed by audiologists, not treatment or surgical services.
- CMS recognizes that occasionally it is necessary to remove non-impacted cerumen prior to the performance of a diagnostic hearing test, but CMS considers this procedure to be a component of the diagnostic test and not separately reimbursable.
- If a patient is seen by an audiologist and impacted cerumen needs to be removed, the patient may be presented with a Notice of Exclusion from Medicare Benefits (NEMB) informing the patient that the service about to be performed is not covered by Medicare and that he/she (and/or another insurer) is expected to pay for the service
Disclaimer: The purpose of the information provided above by the American Academy of Audiology Coding and Reimbursement Committee is to provide general information and educational guidance to audiologists. Action taken with respect to the information provided is an individual choice. The American Academy of Audiology hereby disclaims any responsibility for the consequences of any action(s) taken by any individual(s) as a result of using the information provided, and reader agrees not to take action against, or seek to hold, or hold liable, the American Academy of Audiology for the reader’s use of the information provided. As used herein, the “American Academy of Audiology” shall be defined to include its directors, officers, employees, volunteers, members, and agents.