Otolaryngology Coding Alert

Question: My patient’s tube went into the middle ear. The physician took her to the operating room and removed the tube from the middle ear canal and replaced the tube with a longer one through the same site. His operative report states, “An anterior inferior myringotomy was made and through small pick manipulations the foreign body in the middle ear which was the t-tube that had fallen in, was carefully teased out and removed. Then a new longer t-tube was inserted into the same site.” Can I charge a middle ear exploration (69440) in addition to 69436 for myringotomy with tube insertion?

Pennsylvania Subscriber

Answer: Even if the operative note shows middle ear exploration but does not document medical necessity for doing the exploration, you cannot code 69440 (Middle ear exploration through postauricular or ear canal incision). If you don’t have the supporting documentation for including 69440 on the claim, only report 69436 (Tympanostomy [requiring insertion of ventilating tube], general anesthesia).