Cerumen Removal or E/M

Would you choose 69210 or 99213 for this report? I am leaning towards 99213 because i dont feel the documentation is not supporting significant amount of time and effort need to clean ou Cerumen. thoughts?

Patient seen for a main issue of what he thought was some
impacted wax in his ears. His left ear has felt "hollow" when talking. He actually has no symptoms in the right ear. Not been dizzy. Is overall in very good health for his age.

EXAM:
General appearance shows a pleasant.
The ears are both examined under the microscope. Right side actually has
significant impaction of cerumen, which is cleared. The canal and drum
otherwise look normal. On the left side, there is just a trace of cerumen,
which is cleaned, but the canal and drum are normal. No signs for effusion.

ASSESSMENT AND PLAN:
His right ear actually had the most cerumen, whereas the left was clear. Patient just wanted to see if the ears needed to be cleaned today or if there was anything like fluid or something overtly wrong. He will be back for more assessment if he is having lingering issues, and if he is agreeable with doing the hearing test.

re: Cerumen Removal or E/M

69210 if it was me. A significant impaction was found and cleared with a microscope

re: Cerumen Removal or E/M

So, if 69210 were to be used, no E/M for the office visit unless the patient is also seen for other problems?

re: Cerumen Removal or E/M

Correct.

re: Cerumen Removal or E/M

Can depend on the payor. Some will not pay cerumen inpaction separately unless the provider documents use of curette or other instrument. Washing technique is not separately payable considered part of the E & M by certain payors.

re: Cerumen Removal or E/M

Sounds like the ears were main focus. I go with Cerumen.