Otolaryngology Coding Alert

Question: A patient with a long history of eustachian tube dysfunction visits the otolaryngologist complaining of  a plugged ear. A right pressure equalization (PE) or ventilating tube is present in the anterior inferior quadrant. The physician determines that crust around the tube is causing the discomfort. An attempt is made to remove the crust from the tube, but it is very adherent. The otolaryngologist extracts the tube and replaces it with a clean one. How should replacement of the tube be coded?

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Answer: The answer depends on whether general anesthesia was administered and whether the original tube was placed by the otolaryngologist or another physician. If general anesthesia was administered, use 69436 (tympanostomy [requiring insertion of ventilating tube], general anesthesia); if general anesthesia was not administered, use 69433 (tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia).
 
If the otolaryngologist that is inserting the new tube also placed the original one, the removal of the original tube cannot be reported separately, as it is included in the original insertion. Even if the original insertion was performed by another physician, most carriers would likely consider removal of the tube (69424, ventilating tube removal when originally inserted by another physician) as part of 69436 or 69433 (because much of the otolaryngologist's work would be duplicated), even though 69424 is not bundled with either code in the CCI.