LOCATION: Outpatient, HospitalPATIENT: Daniel Briggstad ATTENDING PHYSICIAN: Jeff King, MD

SURGEON: Jeff King, MD

PREOPERATIVE DIAGNOSES

1. Recurrent otitis media.

2. Retained right PE tube and granulation tissue.

3. Left otitis media with effusion.

POSTOPERATIVE DIAGNOSES

1. Recurrent otitis media.

2. Retained right PE tube and granulation tissue.

3. Left otitis media with effusion.

4. Right tympanic membrane perforation.

PROCEDURES PERFORMED

1. Removal of right PE tube and granulation tissue from the tympanic membrane.

2. Left myringotomy with tympanostomy tube placement.

ANESTHESIA: General inhalation.

SURGICAL INDICATIONS: A 4-year-old male with a history of bilateral PE tubes. Since extrusion of the PE tubes, he has had recurrent episodes of otitis media. There is also granulation tissue around the right PE tube.

PROCEDURE: After consent was obtained, the patient was taken to the operating room and placed on the operating table in supine position. After the adequate level of general inhalation anesthesia was obtained, the patient was draped in the appropriate manner for PE tube placement. Attention was first focused on the right ear. Utilizing an ear speculum and microscope, the external canal was cleared of cerumen. The retained extruded PE tube was removed from the tympanic membrane. In addition, granulation tissue was also removed. Subsequent examination shows a perforation of the posterior inferior area. There is no effusion. Due to the significant size of the perforation, no PE tube was placed. Attention was then focused on the left side. The ear canal was cleared of wet debris and cerumen. The tympanic membrane was noted to be opaque. The myringotomy incision was then placed in the anterior inferior quadrant. Serous effusion was suctioned. A bobbin tympanostomy tube was then placed without difficulty. Cortisporin otic suspension and a cotton ball were then placed.

The patient tolerated the procedure well, and there was no break in technique. The patient was awakened and taken to the postanesthesia area in good condition.

Abstracting & Coding Questions:

1. Was the removal of the tube from the right ear reported?

2. Was the removal of the tube from the left ear reported?

3. What procedure was performed on the left ear?

4. What three modifiers were reported with the CPT codes assigned for this case?

5. What CPT code(s) would be reported for this case?

6. What ICD-10-CM code(s) would be reported for this case?

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