procedure code and description
69436 – Tympanostomy (requiring insertion of ventilating tube), general anesthesia – average fee payment – $170 – $180
69420 Myringotomy including aspiration and/or eustachian tube inflation
69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia
69424 Ventilating tube removal requiring general anesthesia
69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia
69799 Unlisted procedure, middle ear S2225 Myringotomy, laser-assiste
Policy: A myringotomy (69420, 69421, or S2225) may be performed with or without the insertion of tympanostomy tubes. Insertion of tubes should be reported under code 69433 or 69436, as appropriate.
Removal of ventilation, myringotomy, or tympanostomy tubes (i.e., Shea or Collar button) may be paid when performed under general anesthesia (69424).
However, removal of such tubes is considered an integral part of a doctor’s medical care when not performed under general anesthesia, and therefore, is not eligible as a distinct and separate service.
Mutually exclusive procedures
For example, CPT codes 69433 and 6 436 describe different types of tympanostomy requiring insertion of ventilating tube. CPT ode 69433 describes the procedure performed with local or topical ane thesia, and CPT code 69436 describes the procedure performed with general anesthesia. Since both procedures would not be performed at the same patient encounter, the two procedures are mutually exclusive of one another.
Bilateral Procedures: Billing Clarification
When billing for bilateral procedures performed during the same session (unless otherwise directed in CPT), providers are to use the -50 modifier (Bilateral procedure) with the appropriate CPT code and place a “1” in the units field of the claim form. The site specific modifiers ‘LT’ (Left side) or ‘RT’ (Right side) may be used on appropriate CPT codes only when services are performed on either the right OR the left side.
Providers should not use the ‘LT’ and ‘RT’ modifier on the same procedure code instead of the -50 modifier. For example, during the same session it is not appropriate to use the ‘RT’ and ‘LT’ on CPT procedure code 69436 (Tympanostomy…) when performed bilaterally.
For questions related to this clarification, please contact Molina Medicaid Solutions Provider Services at (800)-473-2783 or (225)-924-5040.
Providers will no longer be able to bill for bilateral procedures on two lines with/without the modifi er -50, or on one line with a count of two.
Example: CPT 69436 billed with a 50 modifi er on a single date of service. CPT code billed a second time for the same date of service without the modifi er 50.
CODE DESCRIPTION RULE LINE
69436-50 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), ALLOW ALLOW GENERAL ANESTHESIA
69436 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), DISALLOW DISALLOW GENERAL ANESTHESIA
• Procedure code 69436 was performed bilaterally and submitt ed once with the modifi er -50.
• The second submission of procedure code 69436 with or without modifi er 50 is not recommended for separate reporting, because the procedure code was previously billed once on the same date of service with the modifier -50.