Impacted cerumen, bilateral

This code signifies the presence of hardened earwax obstructing both ear canals. This impaction can lead to symptoms such as hearing loss, earache, tinnitus, or a feeling of fullness in the ears. It represents a condition where cerumen has accumulated to the point of causing symptoms or preventing adequate examination of the tympanic membrane.

This code is appropriate when documentation clearly indicates impacted cerumen affecting both ears. It should be used when a provider diagnoses bilateral earwax blockage that requires removal or is causing patient symptoms. Supporting documentation typically includes physician notes detailing the presence of cerumen in both external auditory canals and its obstructive nature.

• Ensure documentation specifies "bilateral" involvement; otherwise, use codes for unilateral or unspecified ear.
• Do not code for routine cerumen removal unless the cerumen is documented as impacted and symptomatic.
• Consider sequencing this code as a primary diagnosis if it is the reason for the encounter, or as a secondary diagnosis if it's an incidental finding or contributing factor to another condition.