**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 physicians 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.

HCPCS code G0268 should be billed only where a physician's skill is needed to
remove impacted cerumen on the same day as audiologic function testing
performed by his/her employed audiologist. This code should not be used when
the audiologist removes the cerumen, because removal of cerumen is considered
to be part of the diagnostic testing and is not paid separately.  
  
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.)