dyoungberg
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I need help coding the following Op Note please..................
PROCEDURE:
1. REMOVAL OF RETAINED PE TUBE BOTH EARS
2. LEFT EAR MYRINGOTOMY WITH PLACEMENT OF PE TUBE
ANESTHESIA: GENERAL VIA MASK
INTRAOPERATIVE FINDINGS: Retained PE tube in both ears. The patient has a small perforation of the right TM. There is a minimal amount of fluid in the left ear.
DESCRIPTION: The right ear was examined under the microscope. There we see the PE tube which is not functional. The PE tube is encrusted with cerumen. The PE tube was removed revealing a small perforation. The decision was made to leave the perforation and to not insert another PE tube. Next, the left ear was examined under the operating microscope. There is a PE tube in the ear canal which was removed. Next, we made a myringotomy incision on the anterior superior quadrant of the TM. A Donaldson PE tube was inserted without difficulty. Floxin drops were instilled into both ears. The surgery was concluded at this time. The patient was reversed from anesthesia. She was awake, alert, and transferred to recovery in stable condition.
I believe I can only code 69436 for the Myringotomy with PE Tube placement. My concern is this is done in the left ear only. The doctor removed PE Tubes from both ears. 69424 is bundled in with 69436-is it correct to use 69424-RT and 69436-50?
I appreciate any help!
PROCEDURE:
1. REMOVAL OF RETAINED PE TUBE BOTH EARS
2. LEFT EAR MYRINGOTOMY WITH PLACEMENT OF PE TUBE
ANESTHESIA: GENERAL VIA MASK
INTRAOPERATIVE FINDINGS: Retained PE tube in both ears. The patient has a small perforation of the right TM. There is a minimal amount of fluid in the left ear.
DESCRIPTION: The right ear was examined under the microscope. There we see the PE tube which is not functional. The PE tube is encrusted with cerumen. The PE tube was removed revealing a small perforation. The decision was made to leave the perforation and to not insert another PE tube. Next, the left ear was examined under the operating microscope. There is a PE tube in the ear canal which was removed. Next, we made a myringotomy incision on the anterior superior quadrant of the TM. A Donaldson PE tube was inserted without difficulty. Floxin drops were instilled into both ears. The surgery was concluded at this time. The patient was reversed from anesthesia. She was awake, alert, and transferred to recovery in stable condition.
I believe I can only code 69436 for the Myringotomy with PE Tube placement. My concern is this is done in the left ear only. The doctor removed PE Tubes from both ears. 69424 is bundled in with 69436-is it correct to use 69424-RT and 69436-50?
I appreciate any help!