Vol. 16 •Issue 12 • Page 10
Coding Corner
Coding Auditory System Procedures
Case Study 1
Preoperative Diagnosis: Adhesive otitis, left ear.
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 Report: After the induction of adequate general anesthesia, the patient was put into 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 Code Assignments
Preoperative Diagnosis: Adhesive otitis, left ear.
385.10 Adhesive middle ear disease, unspecified as to involvement
Postoperative Diagnosis: Adhesive otitis, left ear.
385.10 Adhesive middle ear disease, unspecified as to involvement
CPT Code Assignments, Rationale
Select the procedures to be coded from the above operative report. In the above case, two procedures were performed.
The surgeon examined the patient’s 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 general anesthesia, the right ear is examined and the T-tube in place was found to be patent. To assign the code for the T-tube placement, identify the term of the procedure to be coded. In this case, it is tympanostomy.
Check the term Tympanostomy in the CPT index. This term is listed alone, and the code range 69433-69436 follows it. Look up each of these codes in the auditory system subsection of the surgery section of the CPT manual and read the descriptions. Compare the procedure and anatomic site described in the operative report above against each of these codes.
After doing so, you will see that CPT code 69436 is the correct choice, and it should be assigned for both the facility and professional components. To indicate that the tube was placed in the left ear canal, you would assign modifier LT to the facility component. Modifier LT is not required for the professional component.
In addition to performing a tympanostomy, the surgeon “visualized” the right ear “with the operating microscope” and cleared the canal of debris.
To report this, refer to the term Otolaryngology under which the term Diagnostic is listed. The phrase Exam Under Anesthesia is indented under the word Diagnostic and is followed by code 92502. Before assigning, check the code description to confirm that it matches the description of the procedure performed.
To communicate that the ear exam was a separate procedure from the tube insertion of the left ear, assign modifier 59 (distinct procedural service) for both the facility and professional components.
You also must assign modifier RT (right side) to this code for the facility component to show that it was the right ear that was examined.
Note that the physician listed “myringotomy” under procedure performed, and this term is also included in the operative report. Even though this term, which identifies the surgical incision of the eardrum, appears twice in the documentation, it is not the code looked up in the index.
The fact that a ventilating tube has been inserted turns this procedure into a tympanostomy, which codes to 69436.
Summary of CPT Codes
Facility Component:
69436-LT Tympanostomy (requiring insertion of ventilation tube), general anesthesia
92502-59-RT Otolaryngologic examination under general anesthesia
Professional Component:
69436 Tympanostomy (requiring insertion of ventilation tube), general anesthesia
92502-59 Otolaryngologic examination under general anesthesia
Case Study 2
Preoperative Diagnosis: Meniere’s disease.
Postoperative Diagnosis: Meniere’s disease.
Procedure Performed: Gentamycin ablation, left ear.
Anesthesia: Local with 1% Xylocaine with epinephrine and 4% topical Xylocaine supplemented by IV sedation.
Operative Report: With the patient in the supine position, the left ear was prepped with Betadine in a sterile manner. The operating microscope was brought into the field, and the posterior canal skin was infiltrated with 1% Xylocaine with epinephrine. The tympanic membrane was then palpated and found to be anesthetized.
A posterior tympano-meatal flap was elevated and reflected forward in a routine manner. The middle ear was entered, and a pledget of cotton with 4% Xylocaine was placed. The round window was readily apparent, and a small pledget of gel foam soaked in Gentamycin solution was placed in the round window notch. The middle ear was then filled with Gentamycin 40 mg per cc. The tympano-meatal flap was suctioned back into position and secured with a pledget of pressed dry-gel foam. The external ear canal was then filled with Polysporin ointment.
The patient tolerated the procedure well and left the operating room in good condition.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Meniere’s disease.
386.00 Meniere’s disease, unspecified
Postoperative Diagnosis: Meniere’s disease.
386.00 Meniere’s disease, unspecified
CPT Code Assignments, Rationale
The ablation of the middle ear was done with a Gentamycin solution placed on a pledget and then instilled into the ear.
Currently, there is not a specific CPT code for this procedure. CPT guidelines state that if a CPT code has not been developed for a procedure, an unlisted code must be assigned.
Refer to the entry Unlisted Services and Procedures in the CPT index. Look then for the term Ear, then the indented term middle ear, where code 69799 is listed. This is the correct code to assign. Modifiers are not required for unlisted codes.
Summary of CPT Codes
Facility Component
69799 Unlisted procedure, middle ear
Professional Component
69799 Unlisted procedure, middle ear
Monica Kiesecoms is a senior health care consultant, Medical Learning Inc., (MedLearn), St. Paul, MN.
