69420 vs 69421

dyoungberg

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I am unsure which code is correct to use with this procedure in an ASC setting.

With the patient appropriately identified in the preop holding area, she was taken to the OR and placed upon the OR table. Local MAC anesthesia was induced. The left ear was well visualized. Filling the ear canal there is purulent fluid. Using a Lukens trap cultures were collected. The PE tube is identified. A small myringotomy inferior to the PE tube was created to allow the PE tube to be extracted. The TM is very thickened and inflamed. The PE tube was removed with a straight pick atraumatically. In the middle ear space there is more purulent fluid present and this is evacuated with suctioning. Granulation tissue appears to fill in the middle ear space. Small cup forceps were used to collect tissue for biopsy. Next, using Betadine solution the middle ear space was copiously irrigated and suctioned dry. The mastoid is palpated. It is not fluctuant and no overlying cellulitis. After copious irrigation, Floxin drops were instilled into the ear canal and a cotton ball was placed. The patient was handed back to anesthesia and went back to recovery in stable condition.

With everything I have read on MAC it appears 69420 would be correct. I'm second guessing myself and would like some feed back on how others would approach this.

Thanks very much!

Debbie Youngberg
AAPC-A
 
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