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69436 - no new incision

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amymauney17@gmail.com

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I have a surgeon who is reporting a bilateral 69436. On the right side his notes state incision made and tube placed. However, on the left side his notes state he removed an existing tube and placed a new one. He did not make a new incision. Is this still considered 69436 without making a new incision? All sources we've researched say to still use 69436 but our concern is if audited, how can we defend this code without a note of "myringotomy incision made"?
 
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