Cerumen Management

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)).

No. 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.) Under Medicare, these services are only reimbursable when performed by physicians and other qualified non-physician practitioners (e.g., physician assistant, nurse).

Because audiologists are reimbursed for only diagnostic services under the Medicare program, cerumen removal is considered an excluded, non-covered service; therefore the patient should pay for the service at the time it is rendered. A voluntary Advanced Beneficiary Notice (ABN) may be offered to the patient prior to performing the procedures so they are aware of their fiscal responsibility, should they choose to have this procedure performed.

Non-covered services are typically not submitted to Medicare however, some third party payers do reimburse for cerumen removal when performed by an audiologist. If you must bill Medicare for a third party denial, use the GY (procedure is not a covered service) and -GX (voluntary ABN issued to patients).

Chart documentation should include the time, effort, and equipment necessary to provide the service. Additionally, ‘impaction’ should be substantiated based on clinical definitions and standards of practice (see below re: “How is ‘impacted’ defined?”).

Cerumen removal (non-impacted) 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.

A major determining factor in the reporting of CPT codes 69209 and 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.

In the United States, the scope of clinical practice in audiology is determined at the state level via licensure laws and statutes. Each state licensing body for audiologists will have their own relevant state codes and laws related to their professional practices. Providers are encouraged to seek primary references in state laws/code and direct clarification questions to the appropriate board overseeing audiology licensure.

Coverage policies for Medicaid programs will vary by state. It is unlikely that cerumen management services are covered when performed by audiologists because codes 69209 and 69210 are considered surgical codes. Providers should seek state-specific and policy-specific (in the case of Medicaid Managed Care options) to determine whether audiologists would be reimbursed for cerumen management services. Similarly, plan specific evidence of coverage policies should be obtained for private plans to determine whether cerumen management codes will be reimbursable when provided by audiologists.