CMS Cerumen (Earwax) Removal Form
This procedure is not covered
Background for this Policy
Summary Of Evidence
N/A
Analysis of Evidence
N/A
Abstract:
Cerumen impaction is a condition in which earwax has become tightly packed in the external ear canal to the point that the canal is blocked. Extraction requiring methods beyond simple irrigation or removal by Q-tip or cotton-tipped applicator may require a physician's skill. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.
Cerumen, or ear wax, is the product of desquamated skin mixed with secretions from the adnexal glands of the external ear canal. It provides lubrication, acts as a vehicle for the removal of contaminants away from the tympanic membrane and prevents dessication of the epidermis.
Though usually asymptomatic, cerumen can accumulate and become impacted causing such symptoms as conductive hearing loss, pain, itching, cough, dizziness, vertigo, and tinnitus. Hearing impairment can further contribute to stress, social isolation, and depression. Impacted cerumen can also impede the evaluation and management of other otologic conditions.
Depending on the case, different methods are used to remove impacted cerumen. Simple irrigation with a bulb syringe with or without chemical softeners is often effective and generally does not require a physician's skill. Forced irrigation with a metal hand-held syringe or an electric oral jet irrigator may be necessary in some cases. A few may need manual disimpaction under direct vision using suction, probes, forceps, hooks or other instruments. Cases requiring methods beyond simple irrigation or removal by Q-tip or cotton-tipped applicator may require a physician's skill. Particularly complex or risky cases usually do.
Indications:
The following applies to all payable cerumen disimpaction, CPT 69210 and HCPCS code G0268
Medically necessary removal of impacted cerumen requires a physician's skill when removal by an individual other than a physician or qualified non-physician practitioner poses an unacceptable risk of complications such as tympanic membrane perforation.
Cerumen removal requiring a physician’s skill may include cases where the tympanic membrane cannot be observed (e.g., total occlusion or impaction), there are overt medical contraindications such as anatomical abnormalities, surgical modifications, or risk of infection, presence of medical conditions that pose undue risk of excessive bleeding (e.g., use of anticoagulants), or the cerumen cannot be removed safely without undue risk of abrasion, laceration, or tympanic membrane perforation.
Removal of impacted cerumen is covered if it is reasonable and necessary for the diagnosis or treatment of illness or injury.
Payment is made for impacted cerumen removal requiring a physician's skill when personally performed by a physician.
Payment may be made only for: a) medically necessary removal of symptomatic impacted cerumen; b) medically necessary removal of impacted cerumen impeding the physician's ability to properly evaluate or manage other signs, symptoms or conditions (e.g., examination of the tympanic membrane in cases of otitis media); or c) medically necessary removal of impacted cerumen impeding a physician's or audiologist's ability to perform covered, medically necessary audiometry.
Payment may be made for both removal of impacted cerumen and an E/M service only if the E/M service represents a medically necessary, significant and separately identifiable service that is supported by medical record documentation.
Payment for G0268 may be made to a physician whose skill is required to remove impacted cerumen on the same date as his or her employed audiologist performs audiologic function testing.
Limitations:
Billing and reimbursement for CPT code 69210 or HCPCS code G0268 is limited to clinical circumstances where documentation supports these to be reasonable and necessary services requiring a physician's skill. The routine removal of asymptomatic, non-impacted, non-obstructive cerumen does not generally require a physician's skill and is thus not considered reasonable and necessary.
Visualization aids, such as, but not necessarily limited to binocular microscopy, are considered to be included in the reimbursement for CPT code 69210 and HCPCS code G0268 and should not be billed separately.
When the sole reason for the visit is the medically necessary removal of symptomatic impacted cerumen, an E&M service may not also be billed in addition.
An E&M service on the same day as removal of impacted cerumen may not be billed unless it represents and is documented to be a significant, separately identifiable service on the same day.
For example:
It is recognized that audiologists' education, experience or practice may include or require techniques of cerumen removal. However, Medicare can pay audiologists only for medically necessary diagnostic testing, which is considered to include any incidental cerumen removal by the audiologist. Medicare cannot reimburse audiologists for CPT code 69210 or HCPCS code G0268 under any circumstances.
Other Comments:
For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.
Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.
Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)
Cerumen impaction is a condition in which earwax has become tightly packed in the external ear canal to the point that the canal is blocked. Extraction requiring methods beyond simple irrigation or removal by Q-tip or cotton-tipped applicator may require a physician's skill. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.
Cerumen, or ear wax, is the product of desquamated skin mixed with secretions from the adnexal glands of the external ear canal. It provides lubrication, acts as a vehicle for the removal of contaminants away from the tympanic membrane and prevents dessication of the epidermis.
Though usually asymptomatic, cerumen can accumulate and become impacted causing such symptoms as conductive hearing loss, pain, itching, cough, dizziness, vertigo, and tinnitus. Hearing impairment can further contribute to stress, social isolation, and depression. Impacted cerumen can also impede the evaluation and management of other otologic conditions.
Depending on the case, different methods are used to remove impacted cerumen. Simple irrigation with a bulb syringe with or without chemical softeners is often effective and generally does not require a physician's skill. Forced irrigation with a metal hand-held syringe or an electric oral jet irrigator may be necessary in some cases. A few may need manual disimpaction under direct vision using suction, probes, forceps, hooks or other instruments. Cases requiring methods beyond simple irrigation or removal by Q-tip or cotton-tipped applicator may require a physician's skill. Particularly complex or risky cases usually do.
Indications:
The following applies to all payable cerumen disimpaction, CPT 69210 and HCPCS code G0268
Medically necessary removal of impacted cerumen requires a physician's skill when removal by an individual other than a physician or qualified non-physician practitioner poses an unacceptable risk of complications such as tympanic membrane perforation.
Cerumen removal requiring a physician’s skill may include cases where the tympanic membrane cannot be observed (e.g., total occlusion or impaction), there are overt medical contraindications such as anatomical abnormalities, surgical modifications, or risk of infection, presence of medical conditions that pose undue risk of excessive bleeding (e.g., use of anticoagulants), or the cerumen cannot be removed safely without undue risk of abrasion, laceration, or tympanic membrane perforation.
Removal of impacted cerumen is covered if it is reasonable and necessary for the diagnosis or treatment of illness or injury.
Payment is made for impacted cerumen removal requiring a physician's skill when personally performed by a physician.
Payment may be made only for: a) medically necessary removal of symptomatic impacted cerumen; b) medically necessary removal of impacted cerumen impeding the physician's ability to properly evaluate or manage other signs, symptoms or conditions (e.g., examination of the tympanic membrane in cases of otitis media); or c) medically necessary removal of impacted cerumen impeding a physician's or audiologist's ability to perform covered, medically necessary audiometry.
Payment may be made for both removal of impacted cerumen and an E/M service only if the E/M service represents a medically necessary, significant and separately identifiable service that is supported by medical record documentation.
Payment for G0268 may be made to a physician whose skill is required to remove impacted cerumen on the same date as his or her employed audiologist performs audiologic function testing.
Limitations:
Billing and reimbursement for CPT code 69210 or HCPCS code G0268 is limited to clinical circumstances where documentation supports these to be reasonable and necessary services requiring a physician's skill. The routine removal of asymptomatic, non-impacted, non-obstructive cerumen does not generally require a physician's skill and is thus not considered reasonable and necessary.
Visualization aids, such as, but not necessarily limited to binocular microscopy, are considered to be included in the reimbursement for CPT code 69210 and HCPCS code G0268 and should not be billed separately.
When the sole reason for the visit is the medically necessary removal of symptomatic impacted cerumen, an E&M service may not also be billed in addition.
An E&M service on the same day as removal of impacted cerumen may not be billed unless it represents and is documented to be a significant, separately identifiable service on the same day.
For example:
- If the patient has pain in the external ear as his/her only complaint and the removal of cerumen addresses that complaint, one should bill only for removal of the cerumen, CPT code 69210.
- If the patient also has symptoms of otitis media requiring further evaluation, then it may be justified to also bill for an E&M service with modifier –25.
It is recognized that audiologists' education, experience or practice may include or require techniques of cerumen removal. However, Medicare can pay audiologists only for medically necessary diagnostic testing, which is considered to include any incidental cerumen removal by the audiologist. Medicare cannot reimburse audiologists for CPT code 69210 or HCPCS code G0268 under any circumstances.
Other Comments:
For claims submitted to the Part A MAC: This coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC. to process their claims.
Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.
Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.
For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.
For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections 410.74, 410.75, 410.76 and 419.22; 58 FR 18543, April 7, 2000.)