Otolaryngology Coding Alert

Question: The surgeon performs a bilateral tube removal under general anesthesia in addition to impacted cerumen removal from the right ear. Do I code 69421, 69210, or both?

Oklahoma Subscriber

Answer: When the surgeon performs two distinct services within the same ear at the same surgical encounter, your first point of reference should be National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits. In this example, you’ll see that 69421 (Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia) and 69210 (Removal impacted cerumen requiring instrumentation, unilateral) are bundled together with a modifier indicator of “1.”

Outside of a scenario where the surgeon performs the two procedures on contralateral ears, you should not report these two services together. If the surgeon had performed a tube removal in the left ear and cerumen removal in the right ear, you could report both procedures using the laterality modifiers to override the bundling edit. In this case, however, you should only report the column 1 (and higher-valued) code, 69421 with modifier 50 (Bilateral Procedure).