Vol. 18 •Issue 16 • Page 9
Coding Corner
Coding Adhesive Otitis
In addition to performing a tympanostomy, the physician also examined the right ear.
Pre- and Postoperative Diagnosis: Adhesive otitis, left ear
Procedure Performed: Myringotomy and tympanostomy tube, left ear; examination under anesthesia of right ear
Anesthesia: General
Indication for Procedure: This child presents with persistent adhesive otitis of the left ear for replacement of ventilating tube.
Operative Technique: After the induction of adequate general anesthesia, the patient was placed in the supine position, the eyes were protected, and the left ear was visualized under the operating microscope.
The canal was cleaned of debris. An anterior inferior myringotomy was performed. Fluid and negative pressure were noted. A modified Richards T-tube was placed without difficulty.
Vasocidin was instilled in the canal. In a like fashion, the right ear was visualized with the operating microscope.
The canal was cleaned of debris. A T-tube was seen in place and patent.
At this point, the procedure was terminated. The patient was awakened in the operating room and brought to the recovery room in stable condition without any blood loss.
ICD-9-CM DIAGNOSIS AND CODE
Pre- and Postoperative Diagnosis: Adhesive otitis, left ear
385.10 Adhesive middle ear disease, unspecified as to involvement
ICD-9-CM PROCEDURE CODES
20.01 Myringotomy with insertion of tube 18.11 Otoscopy
CPT CODING
The surgeon examined the left ear and found debris, fluid and negative pressure. A tympanostomy tube was inserted into the left ear with the use of the operating microscope under general anesthesia.
While the patient is still under the general anesthesia, the right ear is examined, and the T-tube in place was found to be patent.
A T-tube placement is identified by the term “tympanostomy.” To assign the code for the T-tube placement, look up the term
Tympanostomy in the index where code range 69433-69436 is listed. There are only two codes in this range (69433 and 69436). The ease of assignment in this case lies in the fact that the description
for code 69433 indicates that local or topical anesthesia is used, which did not occur in the above case.
After reading the description of the codes, it is easy to see that the following is the correct code:
69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia
For facility coding, you will assign modifier LT (left side) to the above code to communicate that the tube was placed in the left ear canal. For professional coding, no modifier would be assigned.
In addition to performing a tympanostomy, the physician examined the right ear. Reference the term Otolaryngology. The choice after this is easy because under the subterms Diagnostic and Exam under Anesthesia, only the code below, which is the correct choice, is listed.
95202 Otolaryngologic examination under general anesthesia
For facility coding, you will assign modifier RT (right side) to identify the right ear. For physician coding, you will assign modifier 59 (distinct procedural service), but not modifier RT as this is a modifier only used by hospitals.
In summary, here are the codes to assign:
Facility Coding:
69436-LT Tympanostomy (requiring insertion of ventilating tube), general anesthesia
92502-RT Otolaryngologic examination under general anesthesia
Professional Coding:
69436 Tympanostomy (requiring insertion of ventilation tube), general anesthesia
92502-59 Otolaryngologic examination under general anesthesia
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.
