Otolaryngology Coding Alert

Question: My physician performed both tympanostomy tube removal and aural polyp removal under general anesthesia. The otolaryngologist performed both procedures during the same operative session. Can I report both of them?

Colorado Subscriber

Answer: The Correct Coding Initiative (CCI) bundles the tube removal (69424, Ventilating tube removal requiring general anesthesia) into the aural polyp excision (69540, Excision aural polyp). Therefore, you should report only 69540. Keep in mind that the physician must remove the tube to enter the middle ear and excise the polyp, and therefore the tube removal is truly incidental.

Separate-side exception: As with other bundling edits of this type, you may override the edits if the ENT performs separate-side polyp excision and tube removal. For instance, if an otolaryngologist performs bilateral tube removal and excises an aural polyp from a patient’s left ear, you should report: 69540-LT and 69424-59-RT.

Modifier 59 (Distinct procedural service) informs the payer that the tube removal occurred on a separate site from the excision. The body-side modifiers (LT, Left side; RT, Right side) further explain the separate locations.