Otolaryngology Coding Alert

Question: Our provider performed a bilateral myringotomy with tympanoplasty tube placement. The operative report goes into full detail for the right-sided portion of the procedure, but only indicates that “a similar procedure was performed on the left side.” Is this enough documentation to support a bilateral procedure?

Utah Subscriber

Answer: You’ll encounter numerous procedures, typically involving the ears, accessory sinuses, or turbinates, in which the provider uses similar verbiage to indicate a duplicate procedure was performed contralaterally. While the general rule is the more documentation the better, this sort of documentation is not atypical for applicable otolaryngology procedures and does not need to be addended in order to code the procedure bilaterally. You may want to let your provider know that best dictation practices include the details specific to each side — in particular for malpractice defense.