Impacted cerumen, bilateral
ICD-10 H61.23 is a billable code used to indicate a diagnosis of impacted cerumen, bilateral.
Impacted cerumen, or earwax blockage, occurs when excessive earwax accumulates in the ear canal, leading to symptoms such as hearing loss, earache, tinnitus, and a sensation of fullness in the ear. Bilateral impacted cerumen indicates that both ears are affected. This condition is common and can occur in individuals of all ages, but it is particularly prevalent in older adults and those with certain anatomical variations or conditions that predispose them to earwax buildup. Clinical presentation may include difficulty hearing, discomfort, and sometimes dizziness if the blockage affects the vestibular system. Diagnosis is typically made through physical examination using an otoscope, which allows visualization of the ear canal and tympanic membrane. Management often involves cerumen removal techniques, which can be performed in a clinical setting using irrigation, suction, or manual extraction. In some cases, patients may be advised to use ear drops to soften the wax prior to removal. Proper coding for impacted cerumen is essential for accurate billing and reimbursement, as it reflects the patient's condition and the services provided.
Detailed notes on patient symptoms, examination findings, and treatment methods.
Patients presenting with hearing loss, ear pain, or tinnitus due to cerumen impaction.
Ensure documentation reflects the bilateral nature of the condition and any associated symptoms.
Comprehensive history and physical examination notes, including patient-reported symptoms.
Routine check-ups where cerumen impaction is identified during ear examination.
Document any patient education provided regarding ear care and cerumen management.
Used when cerumen removal is performed in the office setting.
Document the method of removal and any patient symptoms.
Otolaryngologists may perform more complex procedures if complications arise.
Common symptoms include hearing loss, earache, tinnitus, and a feeling of fullness in the ear. In some cases, it may also cause dizziness.
