# NEED HELP!!! Bilateral myringotomies and tube placement.



## jwschroeterjr@gmail.com (Feb 24, 2011)

How would you code this report the procedure codes and the diagnosis codes? PREOPERATIVE DIAGNOSES: Chronic otitis media and nasal airway obstruction.

POSTOPERATIVE DIAGNOSES: Chronic otitis media and nasal airway obstruction

PROCEDURES:
1. Bilateral myringotomies and tube placement.
2. Nasal pharyngoscopy.
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: None.
COMPLICATIONS: None. 
INDICATIONS FOR PROCEDURE: The patient is an _______ female with history of recurrent bilateral otitis media and hearing loss. The child had a set of tympanostomy tubes inserted more than a year ago. The infections have recurred. There is also report from the mother that the child is a mouth breather.
DESCRIPTION OF PROCEDURE: General endotracheal anesthesia was obtained. The patient was positioned in the lounge-chair position with the neck gently extended. She was draped in a sterile manner. The operating microscope with a 250-mm lens was then brought into the field. The ear canals were cleaned. The tympanic membranes were clearly visualized. There was an area of tympanosclerosis anteriorly and posteriorly. There was monomeric membrane in between the tube. A radial incision was made on the anteroinferior quadrant of each tympanic membrane through which a titanium bobbin tube was inserted. Several drops of Floxin was used on each side. Attention was then turned to the oral cavity which was maintained open with an McIvor mouth gag. Mirror examination of the nasal pharynx revealed no adenoidal presence, and the nasal pharyngeal airway was patent.
The patient underwent the procedure well. She was allowed to be awakened, extubated, and transferred to the recovery room in satisfactory condition.

Undo
Highl


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## kumar_sanjeev02 (Feb 25, 2011)

*It is only 69436*

Nasal pharynx was examined with mirror, so i think this is not seperately reportable here, so we can code only 69436.

Regards,
Sanjeev Sonkar, CPC


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## Treetoad (Feb 27, 2011)

Don't forget your modifier 50.


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