Code the More Complex Procedure With 69610-RT

Published: 20th July 2011
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In a particular situation, a physician assessed the patient's right ear and cleared the canal of all cerumen. The tympanic membrane was visualized, which had retained a tube. He removed a tube in the anterior superior aspect of the eardrum with a Rosen needle while ciprodex was applied. Post this, a paper patch was placed in an overlay technique and positioned using the operative microscope. After this, the physician went to the left ear and got rid of some dry debris. He also got rid of an extruded tube. There wasn't any perforation in situ; he debrided the canal and applied Ciprodex. As such, how do you report this?

Well, first of all you need to code the more complex procedure with 69610-RT.

Call off these choices: You can't code for the binocular microscope since it's a separate procedure and inclusive minus any other ear procedure carried out. Likewise, the removal of impacted cerumen is also a separate procedure, and insurers take it as inclusive with any other ear procedure. What's more, if the physician carried out this service in the operating room, you can't code 69990 because even though the physician used the operating microscope, coding 69990 requires the use of microsurgical technique. These procedures show no proof of microsurgery.

Next, you should code 69424-59-LT if the doctor carried out this procedure in the operating room under general anesthesia. If the doctor carried out this service under local anesthesia in the OR or in the office, you can code it 92504-59-LT for the use of the binocular microscope as you won't find any code for tube removal when the physician does not use general anesthesia.

Typically, if an otologic procedure requires a transcanal or endaural approach with incision of the tympanic membrane and access through the middle ear, you shouldn't report it separately. But then your physician carried out these services on two ears and should be paid for them as separate procedures. Your claim should look like this: 69610-RT, 69424-59-LT or 92504-59-LT depending on the type of anesthesia the physician used.

For further details on this and for other physician medical billing and coding tips, sign up for a one-stop medical coding guide like Supercoder. Such a site comes stocked with a physician coder's Powerpack that offers powerful physician medical billing and coding tools to provide you everything you need for denial-proof claims. It comes with codesets and tools, specialty coding library, SuperScrubber for physicians, CPT Assistant, and the like.

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