Wiki Coding Op Advice?

[ivonneatanacio]

Provider want to code unlisted?

Procedure: Right myringotomy tube insertion, left middle ear exploration
The patient was brought to the operating room, laid in the supine position, and administered mask anesthesia. An IV has been started and IV med was given. The right was examined. Using the microscope, the ear canal was cleared of cerumen and a myringotomy made in the anterior quadrant. Serous fluid was aspirated, and a beveled grommet tube was inserted and positioned with the pick. Ciprodex drops were instilled. The left ear was then examined with the same microscope and speculum. A pocket of pus was noted anteriorly. A myringotomy was made. Copious pus was aspirated. A tube was inserted, however, inspection upon the middle ear at that time revealed a plaque- like material in the middle ear. The Myringotomy was extended, and then copious cheesy keratin-like material was teased out with dull right angle and sent for permanent histopathologic diagnosis. The tube was removed as this was not clearly an infection fluid, but cholesteatoma needing further intervention and surgery. The patient had drops instilled bilaterally, was awoken from anesthetic, and sent to the recovery room in good condition.

Could I use 69799 similar to 69436?

Thanks in advance for the help.

 

[jjhamer1]

Description of procedure includes, middle ear.

69433-69436 (69433, 69436)

In a patient who has received a local or topical anesthetic (e.g., for 69433) or a general anesthetic (e.g., for 69436), the physician inserts a ventilating tube. Under direct visualization with a microscope, the physician makes a small incision in the tympanum (eardrum). Any middle ear fluid is suctioned and may be reserved for analysis. The physician inserts a ventilating tube into the opening in the tympanum. No other treatment is required.