Abstract from Documentation: What Alphabetic Index term can easily lead to the coding of this case?

History: The patient complains of bilateral ear pain. She denies any decrease in hearing. She has marked cerumen impactions in both ear canals. It took extensive flushing before I was able to get out the wax on both sides. Both canals are now patent.

Physical Examination: Vital signs are stable and she is afebrile.

Assessment: Bilateral cerumen impactions

Plan: I told her she should irrigate both ears once a week with peroxide and warm water.

Under the key term Cerumen, Removal the choices are with Instrumentation or with Irrigation/Lavage.

Underline the supportive documentation. Other than the fact that the physician flushed (irrigation) the ear canals to remove the wax, no other documentation is necessary besides unilateral and bilateral

CPT Code Assignment:
69209-50 Removal impacted cerumen (separate procedure), unilateral
A note appears under code 69210 that instructs to use modifier 50 if it is a bilateral procedure.