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middle ear exploration for removal of lost T-tube

Barbara Posted Fri 15th of January, 2016 16:09:37 PM

My patient's tube went into the middle ear. The physician took her to the operating room and removed the tube from the middle ear canal and replaced the tube with a longer one through the same site. his operative report states " An anterior inferior myringotomy was made and through small pick manipulations the foreign body in the middle ear which was the t-tube that had fallen in, was carefully teased out and removed. Then a new longer t-tube was inserted into the same site" Can i charge a middle ear exploration 69440 in addition to a 69436 myringotomy with tube insertion? I am not sure if the middle ear exploration is appropriate for what was done. thanks in advance

SuperCoder Answered Mon 18th of January, 2016 02:52:59 AM

For the code 69440, even if the op note shows middle ear exploration but does not show medical necessity for doing the exploration, you still cannot code 69440. You must prove the medical necessity of the procedure. Don't report the middle ear exploration if it's not necessary only because it's a higher paying code. It could get you in trouble with your payer.
For the above mentioned procedure code CPT 69436.

Barbara Posted Mon 18th of January, 2016 12:15:13 PM

Thank you. I feel more comfortable with only the 69436 also.

SuperCoder Answered Wed 20th of January, 2016 00:00:38 AM

Happy to help!

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