Local Coverage Determination (LCD)

Cerumen (Earwax) Removal

L33945

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Contractor Information

LCD Information

Document Information

LCD ID
L33945
LCD Title
Cerumen (Earwax) Removal
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 02/04/2021
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862 (a)(7) excludes routine physical examinations.

Section 1862 (a)(1)(A) allows coverage and payment for only those services considered medically reasonable and necessary.

Section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity
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:
  • 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.)
Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information
N/A
Sources of Information
This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators, LLC. is not responsible for the continuing viability of Web site addresses listed below.

McCarter DF, Courtney AU. Cerumen impaction. American Family Academy of Family Physician. >2007;75(10):10.
Bibliography

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Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
02/04/2021 R10

R10

Revision Effective: 02/04/2021

Revision Explanation: Annual Review, no changes were made

1/24/2020:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
09/19/2019 R9

R9

Revision Effective: N/A

Revision Explanation: Annual Review, no changes made

1/24/2020:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review )
09/19/2019 R8

R8

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901. For Approval, no changes.

09/13/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
09/19/2019 R7

R7

Revision Effective: 09/19/2019 Revision Explanation: Converted policy into new policy template that no longer includes coding section based on CR 10901.

09/12/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To Code Removal
04/04/2019 R6
R6
Revision Effective: 04/04/2019
Revision Explanation: Removed all billing and coding details from policy into related Billing and Coding article. Coding information was removed based on CR10901.
 
03/28/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Other (Removed billing and coding details)
01/01/2016 R5

R5

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

01/28/2019:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
01/01/2016 R4

R4
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

01/30/2018:At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
01/01/2016 R3 R3
Revision Effective: 01/01/2016
Revision Explanation: Added new CPT code 69209
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R2 R2
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
10/01/2015 R1 R1
Reveiosn Effective: N/A
Revision Explanation: Accepted revenue code description changes.
  • Other (revenue code description)

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56454 - Billing and Coding: Cerumen (Earwax) Removal
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
01/27/2021 02/04/2021 - N/A Currently in Effect You are here
01/24/2020 09/19/2019 - 02/03/2021 Superseded View
09/13/2019 09/19/2019 - N/A Superseded View
09/12/2019 09/19/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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