CurrentArizona Complete HealthPolicy CC.PP.008

Cerumen (earwax) removal payment policy

Defines payment and billing criteria for removal of impacted cerumen for all Arizona Complete Health products; applies to providers submitting claims for cerumen removal services.

Policy Summary

PayerArizona Complete Health

PolicyCerumen (earwax) removal payment policy

Policy CodePolicy CC.PP.008

Change TypeCoding addition and template/review updates

Effective DateJan 1, 2014

Next Review Date

Key ActionDocument degree of cerumen impaction, the procedure and instrumentation used, and the performing provider's name and credentials to support separate payment when physician skill and instrumentation are required.

SourceLink

POLICY UPDATE CHANGES

Added CPT code 69209 to address removal of impacted cerumen using irrigation/lavage technique (new code effective 2016-01-01).

Converted to new template, added related policies and conducted annual review.

Verified codes and updated references during 02/28/2018 review.

3Situations where separate payment may be made

3CPT/HCPCS codes referenced (69209, 69210, G0268)

4ICD-10 diagnosis codes listed for impacted cerumen

Criteria for Separate Payment

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Criteria for separate payment for cerumen removal

Separate payment for CPT 69210 or HCPCS G0268 is allowed only when documentation supports that physician's skill and instrumentation were required. Routine non-impacted cerumen removal is not separately reimbursed.

ANY of the following

Removal of symptomatic impacted cerumen.
Removal of impacted cerumen impeding the physician's ability to properly evaluate or manage other signs, symptoms or conditions (e.g., preventing examination of the tympanic membrane).
Removal of impacted cerumen impeding a physician's or audiologist's ability to perform covered audiometry.

When physician skill is required

Circumstances considered to require a physician's skill (examples listed in policy).

ANY of the following

Tympanic membrane cannot be observed (e.g., total occlusion or impaction).
Overt medical contraindications (anatomical abnormalities, surgical modifications, risk of infection).
Medical conditions posing undue risk of excessive bleeding (e.g., anticoagulant use).
Cerumen cannot be removed safely without undue risk of abrasion, laceration, or tympanic membrane perforation.

Procedure, Modifier, and Diagnosis Codes

Procedure codesCPT|HCPCSCovered

69209	Removal impacted cerumen using irrigation/lavage, unilateral.
69210	Removal impacted cerumen requiring instrumentation, unilateral.
G0268	Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing.

ModifiersModifier

-25	Significant, separately identifiable E/M service by the same provider on the same day (may be used when E/M is separately identifiable).
-59	Distinct procedural service (may be appended to 69210 when E/M billed by same provider same day and criteria met).

Diagnosis codes (ICD-10-CM)ICD-10

H61.20	Impacted cerumen, unspecified ear.
H61.21	Impacted cerumen, right ear.
H61.22	Impacted cerumen, left ear.
H61.23	Impacted cerumen, bilateral.

Documentation and Billing Rules

Documentation Required

Documentation required to support separate payment

Document the degree of cerumen impaction, the procedure performed, the instrumentation used, and the name and professional credentials of the performing provider. When separate payment is sought for 69210 or G0268, also document why physician skill was necessary (clinical reason such as symptoms, obstruction preventing exam, or interference with audiology) and the specific circumstances that required physician-level instrumentation or technique.

69210
G0268

Billing Rule

Billing when E/M and cerumen removal occur same day

If cerumen removal required physician work and instrumentation and an E/M is billed by the same provider on the same day, append modifier -59 to 69210 to seek separate payment. Do not bill a separate E/M if the sole reason for the visit is cerumen removal; an E/M may be billed with -25 only when a significant, separately identifiable service beyond cerumen removal is documented.

69210
69209
G0268
-25
-59

Billing Rule

Use of G0268

HCPCS G0268 should be billed only when a physician removes impacted cerumen on the same day as audiologic function testing performed by the physician's employed audiologist; do not use G0268 if the audiologist removes the cerumen because that is part of diagnostic testing and is not paid separately.

G0268

Billing Rule

Inclusion of visualization aids

Visualization aids (for example, binocular microscopy) are considered included in the reimbursement for CPT 69210 and HCPCS G0268 and should not be billed separately.

69210
G0268

Policy Context and Scope

This payment policy defines the criteria for separate payment for removal of impacted cerumen and applies to claims submitted for all Arizona Complete Health products. The policy explains when physician-level intervention is considered necessary, the documentation required to support separate reimbursement, and billing instructions for the relevant CPT/HCPCS codes.

This policy references Medicare Local Coverage Determination L31861 for consistency with Medicare guidance and instructs providers that, for Medicaid members, state Medicaid coverage provisions take precedence where they conflict with this policy; providers should follow the applicable state Medicaid manual when differences exist.

Visualization aids (for example, binocular microscopy) and related instrumentation are considered included in reimbursement for the applicable cerumen removal codes and should not be billed separately. The policy was last reviewed on 02/28/2018 and documents prior coding updates, including the addition of CPT 69209 (effective 2016-01-01) to describe irrigation/lavage cerumen removal.

Policy Update Changes

2016-01-01added code

Added CPT code 69209 to address removal of impacted cerumen using irrigation/lavage technique; new code effective 2016-01-01.

2017-02-06administrative update

Converted to new template, added related policies, and conducted annual review (administrative/template change).

2018-02-28code/reference verificationLatest

Verified codes and updated references during review.

Policy Summary

PayerArizona Complete Health

PolicyCerumen (earwax) removal payment policy

Policy CodePolicy CC.PP.008

Change TypeCoding addition and template/review updates

Effective DateJan 1, 2014

Next Review Date

SourceLink

On This Page

OpenPayer

Cerumen (earwax) removal payment policy

Criteria for Separate Payment

Procedure, Modifier, and Diagnosis Codes

Documentation and Billing Rules

Policy Context and Scope

Defined Terms

Policy Update Changes

Cerumen (earwax) removal payment policy

Criteria for Separate Payment

Procedure, Modifier, and Diagnosis Codes

Documentation and Billing Rules

Policy Context and Scope

Defined Terms

Other Policies to Read

Policy Update Changes