Impacted cerumen, unspecified ear
ICD-10 H61.20 is a billable code used to indicate a diagnosis of impacted cerumen, unspecified ear.
Impacted cerumen, or earwax blockage, occurs when earwax accumulates in the ear canal, leading to symptoms such as hearing loss, earache, or a sensation of fullness in the ear. This condition can affect one or both ears, but when unspecified, it indicates that the clinician has not determined which ear is affected. The accumulation of cerumen can be due to various factors, including excessive earwax production, improper cleaning techniques, or anatomical variations in the ear canal. Clinically, patients may present with complaints of decreased hearing, tinnitus, or discomfort. Diagnosis is typically made through otoscopic examination, where the clinician can visualize the blockage. Management often involves cerumen removal, which can be performed using irrigation, suction, or manual extraction. In some cases, softening agents may be used prior to removal. It is essential to differentiate impacted cerumen from other ear conditions, such as otitis media or external otitis, which may present with similar symptoms but require different management strategies.
Detailed notes on the patient's history, symptoms, and examination findings, including otoscopic results.
Patients presenting with hearing loss or discomfort due to cerumen impaction.
Ensure clear documentation of the procedure performed for cerumen removal and any follow-up care.
Comprehensive history and physical examination notes, including patient-reported symptoms.
Routine ear examinations revealing cerumen impaction during annual check-ups.
Document any attempts at self-removal by the patient and the effectiveness of those attempts.
Used when cerumen removal is performed in the office setting.
Document the method of cerumen removal and any patient response.
Otolaryngologists may use more advanced techniques compared to primary care providers.
Common symptoms include hearing loss, earache, tinnitus, and a feeling of fullness in the ear. Patients may also experience dizziness in some cases.
Diagnosis is typically made through a physical examination using an otoscope to visualize the ear canal and identify the presence of cerumen blockage.
Treatment options include cerumen removal through irrigation, suction, or manual extraction. Softening agents may also be used prior to removal.
