dyoungberg
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ASC Setting-Dr removed ear tubes from 6year old under general anesthesia. I billed with 69424 to Medicaid. They have denied as not covered.
Here is the Op Note:
POSTOPERATIVE DIAGNOSIS: 1.HISTORY OF OTITIS MEDIA
2.RETAINED PE TUBE/IMPLANT, LEFT EAR
PROCEDURE: EXAMINATION UNDER ANESTHESIA WITH DEBRIDEMENT OF RETAINED IMPLANT
ANESTHESIA: GENERAL GAS
FINDINGS:
1. Left ear tube in the ear canal, deeply impacted with cerumen, intact tympanic membrane, no middle ear effusion.
2. The right side has cerumen, requiring cleaning, intact tympanic membrane, no effusion.
COMPLICATIONS: NONE
INDICATIONS: The patient presents with a history of ear infection several years ago and had PE tubes which have never fallen out the ear canal. Removal in the office is difficult due to poor cooperation from the patient.
DESCRIPTION OF PROCEDURE: The patient was identified in the preoperative area and was taken to the OR and placed supine on the OR table. Gas anesthesia was induced. Using the operating microscope the left ear was well visualized through a speculum. The PE tube was visible. This was removed with a curette. It is deeply embedded with impacted cerumen. The ear canal was then irrigated and suctioned dry. The tympanic membrane was clear, no effusion.
Next the right ear was visualized. There is also cerumen only present. This was cleaned. Tympanic membrane is clear. The patient was then handed back to Anesthesia, tolerated the procedure well.
Did I bill this correctly and if so, has anyone had any luck billing for this to Medicaid from ASC and getting paid? If so, how did you appeal?
Thanks very much!
Debbie
NW FL Surgery Center
Here is the Op Note:
POSTOPERATIVE DIAGNOSIS: 1.HISTORY OF OTITIS MEDIA
2.RETAINED PE TUBE/IMPLANT, LEFT EAR
PROCEDURE: EXAMINATION UNDER ANESTHESIA WITH DEBRIDEMENT OF RETAINED IMPLANT
ANESTHESIA: GENERAL GAS
FINDINGS:
1. Left ear tube in the ear canal, deeply impacted with cerumen, intact tympanic membrane, no middle ear effusion.
2. The right side has cerumen, requiring cleaning, intact tympanic membrane, no effusion.
COMPLICATIONS: NONE
INDICATIONS: The patient presents with a history of ear infection several years ago and had PE tubes which have never fallen out the ear canal. Removal in the office is difficult due to poor cooperation from the patient.
DESCRIPTION OF PROCEDURE: The patient was identified in the preoperative area and was taken to the OR and placed supine on the OR table. Gas anesthesia was induced. Using the operating microscope the left ear was well visualized through a speculum. The PE tube was visible. This was removed with a curette. It is deeply embedded with impacted cerumen. The ear canal was then irrigated and suctioned dry. The tympanic membrane was clear, no effusion.
Next the right ear was visualized. There is also cerumen only present. This was cleaned. Tympanic membrane is clear. The patient was then handed back to Anesthesia, tolerated the procedure well.
Did I bill this correctly and if so, has anyone had any luck billing for this to Medicaid from ASC and getting paid? If so, how did you appeal?
Thanks very much!
Debbie
NW FL Surgery Center