Impacted cerumen, unspecified ear

This code signifies the presence of a hardened mass of earwax that obstructs the external auditory canal, without specifying which ear is affected. This impaction can lead to symptoms such as hearing loss, earache, tinnitus, or a feeling of fullness in the ear.

Use this code when documentation confirms impacted cerumen but does not specify laterality (left or right ear). This is appropriate for initial encounters where laterality is not yet determined or if the provider explicitly states "unspecified ear." Documentation should clearly indicate the presence of cerumen impaction.

• Avoid using this code if laterality is documented; instead, use H61.21 (right ear), H61.22 (left ear), or H61.23 (bilateral).
• This code is typically a primary diagnosis when cerumen removal is performed.
• Ensure the medical record explicitly states "impacted cerumen" to support this diagnosis.