Otolaryngology Coding Alert
Verify Incision Before Submitting 69420
Question: Our surgeon documented a procedure as follows:
PROCEDURE (aspiration of eardrum): The right ear was examined using the operative microscope. Cerumen was removed. There was a tympanic membrane perforation (30%) and 5 suction was performed and mucopurulent fluid was aspirated through the perforation in the middle ear space. Chloramphenicol and boric acid powders were gently dusted in the ear. The patient tolerated the procedure well and was discharged from our office in a satisfactory condition and verbal instructions were given to the patient.
He wants to bill 69420, but that is an incisional procedure. His note does not state that he made an incision. How should we code it?
New Hampshire Subscriber
Answer: You are correct in thinking you can only report 69420 (Myringotomy including aspiration and/or Eustachian tube inflation) when the surgeon makes an incision. Without an incision, you should report 92504 (Binocular microscopy [separate diagnostic procedure]) with the appropriate E/M code.
Otolaryngology Coding Alert
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