A four-year-old girl presents to the provider's office complaining of severe right ear pain. Upon examination, impacted cerumen is present in both the right and left ears. The physician removes the impacted cerumen bilaterally using instrumentation. The coder identifies the following codes to describe this visit: 69210 Removal of impacted cerumen, unilateral 69209 Removal impacted cerumen using irrigation/lavage ,unilateral The coder should:

Question

Quizplus · Accepted Answer

The correct coding in this scenario is to report code 69210 with modifier -50, which indicates a bilateral procedure. The physician removed impacted cerumen using instrumentation (not irrigation/lavage), and it was done on both ears, hence the use of modifier -50 with the code for unilateral removal to indicate that the procedure was performed bilaterally.

A Four-Year-Old Girl Presents to the Provider's Office Complaining of Severe