Otolaryngology Coding Alert

Question: An otolaryngologist writes that he performs -bilateral middle ear exploration, with placement of bilateral T-type tubes, foreign-body removal left, with fat-graft myringoplasty.- 

-On evaluation of the right tympanic membrane (TM), the right TM had thick scar and effusion. The middle was widely opened and evacuated. Middle ear was fine, had no signs of cholesteatoma or granulation issue. I placed a T-tube.

-On evaluation of the left ear, I found posteriorly an old tympanostomy tube that I removed. I then posteriorly performed fat-graft myringoplasty. I made a wide anterior incision and found clear, thick attached effusion in the middle ear that I removed. I placed a T-tube.-

Can I code more than the myringoplasty?


New Jersey Subscriber

Answer: Yes. You should also report the tympanostomy on the opposite side from the myringoplasty (69620-LT, Myringoplasty [surgery confined to drumhead and donor area]; Left side) with 69436-59 RT (Tympanostomy [requiring insertion of ventilating tube], general anesthesia; Distinct procedural service; Right side).

Left side: For the -fat-graft myringoplasty- on the left ear, you should report 69620-LT. Do not separately report:

- middle ear exploration (69440, Middle ear exploration through postauricular or ear canal incision). When middle ear exploration results in a procedure (such as 69620), you should charge for the operation, not the middle ear exploration.

- T-tube placement. The National Correct Coding Initiative (NCCI) includes 69436 in 69620.

Also: The foreign-body removal mentioned in the initial operative note turned out to be a T-tube. Because a physician places a tube, it's not a foreign body, so you should not code the -foreign-body removal left.- This procedure instead falls under T-tube removal, which is bundled into the myringoplasty. The surgeon couldn't perform the myringoplasty without removing the tube.

For the procedures on the right ear, you should report 69436-59-RT. The only time you can report 69436 in addition to 69620 is, as your case, when the procedures occur on different ears. To indicate that the tympanostomy occurred on a separate site -- the other ear -- from the myringoplasty, attach modifier 59 to 69436. Once again, you should not separately code the middle ear exploration or the T-tube placement.