Otolaryngology Coding Alert

Question: Prior to performing tympanostomy tube placement, the provider performed a cerumen removal service and myringotomy on the same ear. Can I bill out all three procedures?

New York Subscriber

Answer: Actually, you should only bill out with one code, 69436 (Tympanostomy (requiring insertion of ventilating tube), general anesthesia) or 69433 (Tympanostomy … local or topical anesthesia), depending on the type of anesthesia provided.

With respect to the myringotomy, 69420 (Myringotomy including aspiration and/or eustachian tube inflation) and 69421 (Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia) are fundamental components of the tympanostomy with tube placement procedure.

Additionally, removal of any impacted cerumen is also a necessary component of the underlying tympanostomy procedure. Before performing the myringotomy, the provider will remove any obstructing or impacted cerumen in order to clear the external auditory canal and access the tympanum. Thus, it would not be appropriate to add code 69210 (Removal impacted cerumen requiring instrumentation, unilateral) to the claim.

Fortunately, for those coders who do mistakenly bill one or both of these procedures alongside one another, there are National Correct Coding Initiative (NCCI) edits in place to flag this claim before payment is processed. Codes 69420/69421 and 69210 are column 2 codes of 69433 and 69436, which means that an overriding modifier is necessary to distinguish the procedures as a separately identifiable, distinct procedural service from the tympanostomy and tube insertion. In this case, these procedures are interlinked, so modifier 59 (Distinct procedural service) or an X{EPSU} modifier is not applicable when performed in the same ear.

Caveat: If the physician performs cerumen removal or a separate myringotomy on the ear opposite from the tympanostomy, you may bill separately for the services. However, 69210 is still an included component of myringotomy codes 69420 and 69421, so do not bill the cerumen removal separately when performed with myringotomy. When the physician performs either ear procedure unilaterally, you should apply the respective unilateral modifier code, LT (Left side) or RT (Right side).

For example, for tympanostomy under general anesthesia performed on the left and impacted cerumen removal on the right side only, the coding would be 69436-LT and either 69210-XS-RT or 69210-59-RT depending on whether the payer recognizes the X{ESPU} modifiers.