ICD-10 Coding for Ear Wax Impaction(H61.21, H61.22, H61.23, H61.20)
Complete ICD-10-CM coding and documentation guide for Ear Wax Impaction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Ear Wax Impaction
H61.20-H61.23Primary Range
Disorders of external ear
This range includes codes for cerumen impaction, specifying laterality and bilaterality.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| H61.21 | Impacted cerumen, right ear | Use when impacted cerumen is confirmed in the right ear with symptoms or obstruction. |
|
| H61.22 | Impacted cerumen, left ear | Use when impacted cerumen is confirmed in the left ear with symptoms or obstruction. |
|
| H61.23 | Impacted cerumen, bilateral | Use when impacted cerumen is confirmed in both ears with symptoms or obstruction. |
|
| H61.20 | Impacted cerumen, unspecified ear | Use when impacted cerumen is confirmed but ear laterality is not specified. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for ear wax impaction
Essential facts and insights about Ear Wax Impaction
Primary ICD-10-CM Codes for ear wax impaction
Decision Criteria
clinical Criteria
- Cerumen obstructed visualization of TM
Applicable To
- Impacted ear wax, right ear
Excludes
- Otitis externa (H60.-)
Clinical Validation Requirements
- Cerumen obstructed visualization of TM/external canal
- Hard, dry cerumen causing symptoms
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented correctly.
H61.22 - Impacted cerumen, left ear
Use when impacted cerumen is confirmed in the left ear with symptoms or obstruction.
Applicable To
- Impacted ear wax, left ear
Excludes
- Otitis externa (H60.-)
Clinical Validation Requirements
- Cerumen obstructed visualization of TM/external canal
- Hard, dry cerumen causing symptoms
Coding Notes
Ensure laterality is documented correctly.
H61.23 - Impacted cerumen, bilateral
Use when impacted cerumen is confirmed in both ears with symptoms or obstruction.
Applicable To
- Impacted ear wax, both ears
Excludes
- Otitis externa (H60.-)
Clinical Validation Requirements
- Cerumen obstructed visualization of TM/external canal
- Hard, dry cerumen causing symptoms
Coding Notes
Ensure bilaterality is documented correctly.
H61.20 - Impacted cerumen, unspecified ear
Use when impacted cerumen is confirmed but ear laterality is not specified.
Applicable To
- Impacted ear wax, unspecified ear
Excludes
- Otitis externa (H60.-)
Clinical Validation Requirements
- Cerumen obstructed visualization of TM/external canal
- Hard, dry cerumen causing symptoms
Coding Notes
Ensure laterality is documented if known.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Otitis externa
H60.3Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Ear Wax Impaction to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code H61.21.
Impact
Clinical: Inaccurate clinical records, Regulatory: Non-compliance with ICD-10 requirements, Financial: Potential claim denials
Mitigation Strategy
Always specify right, left, or bilateral, Use templates that prompt for laterality
Impact
Reimbursement: Denial of claims for improper use of 69210, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Ensure documentation meets AAO-HNS criteria for impaction
Impact
Failure to document criteria can lead to audits and denials.
Mitigation Strategy
Ensure all criteria are documented in patient records.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Ear Wax Impaction, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Ear Wax Impaction
Use these documentation templates to ensure complete and accurate documentation for Ear Wax Impaction. These templates include all required elements for proper coding and billing.
Cerumen removal procedure
Specialty: OtolaryngologyRequired Elements
- Patient history
- Otoscopy findings
- Method of removal
- Post-procedure assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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