Retained Pe Tube Removal/Myringotomy

dyoungberg

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I need help coding the following Op Note please..................

PROCEDURE:
1. REMOVAL OF RETAINED PE TUBE BOTH EARS
2. LEFT EAR MYRINGOTOMY WITH PLACEMENT OF PE TUBE

ANESTHESIA: GENERAL VIA MASK

INTRAOPERATIVE FINDINGS: Retained PE tube in both ears. The patient has a small perforation of the right TM. There is a minimal amount of fluid in the left ear.

DESCRIPTION: The right ear was examined under the microscope. There we see the PE tube which is not functional. The PE tube is encrusted with cerumen. The PE tube was removed revealing a small perforation. The decision was made to leave the perforation and to not insert another PE tube. Next, the left ear was examined under the operating microscope. There is a PE tube in the ear canal which was removed. Next, we made a myringotomy incision on the anterior superior quadrant of the TM. A Donaldson PE tube was inserted without difficulty. Floxin drops were instilled into both ears. The surgery was concluded at this time. The patient was reversed from anesthesia. She was awake, alert, and transferred to recovery in stable condition.

I believe I can only code 69436 for the Myringotomy with PE Tube placement. My concern is this is done in the left ear only. The doctor removed PE Tubes from both ears. 69424 is bundled in with 69436-is it correct to use 69424-RT and 69436-50?

I appreciate any help!
 

AngieH

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I believe that even though the Dr. removed both pe tubes, 69424 is bundled into 69436. Since only 1 tube was replaced, the only thing that can be billed is 69436-LT.
 
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I have to respectfully disagree with the above poster...

The way that I interpreted the report was that 69424 was performed in both ears, while 69436 was only performed in the left ear. Therefore, I would bill as follows...

69436-LT
69424-59-RT

The 69424 does bundle with 69436, but only for the left ear in which both procedures were performed. Also, if you bill for implants don't forget L8699 for the tube!

I hope this helps!!
 
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