# Myringotomy



## jrs3181 (Sep 8, 2015)

Dr. did a bilateral ventilation myringotomy with no tubes.  A large cerumen impaction was removed, no tube was placed since no fluid was encountered. Would you still use 69436?


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## ljones88 (Sep 11, 2015)

Without reading the op note I won't know for sure. However, if the physician made an incision only without general anesthesia I would think CPT code 69420 (_Myringotomy including aspiration and/or eustachian tube inflation_) would be more appropriate. If GA was used, CPT code 69421 (_Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia_) would be appropriate. 

Also, there is a bundling issue with 69420/69421 and 69210. Since the myringotomy was completed bilaterally, you wouldn't bill the 69210 with it. However, if the myringotomy was completed on one side and cerumen removal on the other side, you could bill 69210 with a -59 modifer or the -59 subsets depending on the payor that accepts them. 

Hope this helps!


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