Impacted cerumen, right ear
ICD-10 H61.21 is a billable code used to indicate a diagnosis of impacted cerumen, right ear.
Impacted cerumen, or earwax buildup, occurs when excessive earwax accumulates in the ear canal, leading to blockage. This condition can cause symptoms such as hearing loss, earache, tinnitus, and a sensation of fullness in the ear. In some cases, it may also lead to infections or exacerbate existing ear conditions. The right ear designation is crucial for accurate coding, particularly in cases where treatment or intervention is specific to one ear. Diagnosis typically involves a physical examination, where a healthcare provider may use an otoscope to visualize the ear canal and assess the extent of the blockage. Management often includes cerumen removal through irrigation, suction, or manual extraction. In some instances, patients may be advised to use ear drops to soften the wax before removal. Proper documentation of symptoms, examination findings, and treatment provided is essential for accurate coding and reimbursement.
Detailed notes on patient history, examination findings, and treatment methods used for cerumen removal.
Patients presenting with hearing loss or discomfort due to earwax buildup.
Ensure to document the method of cerumen removal and any follow-up care provided.
Comprehensive patient history and symptom description, including any prior treatments attempted.
Routine check-ups where earwax buildup is identified during examination.
Document any referrals to specialists if the condition is recurrent or complicated.
Used when cerumen is removed in the office setting.
Document the method of removal and any patient symptoms.
Otolaryngologists may perform more complex removals compared to primary care providers.
Common symptoms include hearing loss, earache, tinnitus, and a sensation of fullness in the ear.
Diagnosis is typically made through a physical examination using an otoscope to visualize the ear canal.
Treatment options include cerumen removal through irrigation, suction, or manual extraction, and the use of ear drops to soften the wax.
