Find information on impacted cerumen bilateral, including clinical documentation tips, ICD-10 code H61.23, medical coding guidelines, and healthcare best practices for diagnosis and treatment of earwax buildup in both ears. Learn about symptoms, causes, and removal procedures for bilateral cerumen impaction. This resource provides essential information for healthcare professionals, coders, and patients seeking to understand and manage this common ear condition.
Also known as
Impacted cerumen
Earwax blockage in both ears.
Diseases of the ear and mastoid process
Covers various ear conditions, including impacted cerumen.
Disorders of external ear
Includes problems affecting the outer ear canal.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is cerumen impacted in both ears?
Yes
Is there any associated inflammation?
No
Do NOT code as bilateral impacted cerumen. Evaluate for other ear condition or unilateral impacted cerumen.
When to use each related code
| Description |
|---|
| Earwax blockage, both ears |
| Excessive earwax, both ears |
| Earwax impaction, one ear |
Coding H61.23 without specifying right or left ear if documentation supports unilateral impaction can lead to incorrect reimbursement.
Miscoding excessive cerumen (H61.20) as impacted cerumen (H61.23) if no impaction is documented can cause audit issues.
Separately billing cerumen removal (69210) with impacted cerumen diagnosis if irrigation is routine component of removal creates compliance risks.
Patient presents with bilateral ear fullness, hearing loss, and occasional tinnitus. Examination reveals impacted cerumen obstructing both ear canals. Symptoms onset reported approximately two weeks ago, gradually worsening. Patient denies ear pain, fever, dizziness, or discharge. Otoscopic examination confirms the presence of dense, dark brown cerumen bilaterally, occluding the visualization of the tympanic membranes. Diagnosis of impacted cerumen bilateral (ICD-10 H61.23) confirmed. Treatment plan includes cerumen removal via irrigation with warm water. Patient education provided on proper ear hygiene and risks of using cotton swabs. Follow-up appointment scheduled in two weeks to assess hearing improvement and ensure complete cerumen removal. Differential diagnosis considered included otitis media, foreign body in the ear canal, and sensorineural hearing loss. Cerumen impaction treatment success is anticipated. Medical coding for this encounter includes CPT code 69209 for bilateral cerumen removal. Prognosis is excellent with appropriate cerumen management.