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Wiki myringotomy, tympanostomy tube

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annettebec

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Swartz Creek, MI
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2 year old, physician creates myringotomy in ear, suctions fluid and places a tympanostomy tube in eardrum. Bilateral procedure. Would I assign codes 69436 (50) and 69421 (50). Bilateral procedures, would I also assign (51) to 69421 for multiple procedures? Diagnosis is chronic otitis media with effusion - would I use 381.3. Any help appreciated. AB
 
The CPT would be 69436-50 if performed under general anesthesia or 69433-50 if local or topical anesthesia. 69421 is not reported separately. 381.3 is correct for chronic OM with effusion.
 
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