Myringotomy and Tympanostomy Tube Placement
6943669433wRVU: 1.53 — Tympanostomy with local or topical anesthesia (1.53 wRVU)69421wRVU: 1.74 — Myringotomy including aspiration, general anesthesia, without tube insertion (1.74 wRVU)69420wRVU: 1.35 — Myringotomy including aspiration, local/topical anesthesia, without tube insertion (1.35 wRVU)69424wRVU: 0.83 — Ventilating tube removal requiring general anesthesia (0.83 wRVU, 0-day global)
Recurrent acute otitis media / chronic otitis media with effusion / eustachian tube dysfunction
Same
Bilateral myringotomy and tympanostomy tube placement
[Attending name], MD
[Resident/Fellow/PA name]
General inhalational (mask) / local
Patient presents with [recurrent AOM (≥3 episodes in 6 months or ≥4 episodes in 12 months, with middle ear effusion present at time of assessment) / chronic bilateral OME ≥3 months with conductive hearing loss, speech delay, or at-risk condition (Down syndrome, cleft palate, ASD, craniofacial anomaly)]. [Bilateral] middle ear effusion confirmed on [pneumatic otoscopy / tympanometry]. Conservative management for [X months] failed. Risks including persistent perforation, tube extrusion, and otorrhea discussed. Consent obtained.
Bilateral tympanic membranes [dull / retracted / with effusion]. [Amber / grey] effusion present bilaterally. [Fluid expressed on myringotomy: serous / mucoid / purulent.] Landmarks [visible / obscured]. No cholesteatoma.
The patient was brought to the operating room. Inhalational general anesthesia administered via mask [without intubation]. The patient was positioned supine and the ear canal cleaned under the operating microscope.
RIGHT EAR: The ear canal was cleaned of cerumen. The tympanic membrane was visualized with the operating microscope. A radial myringotomy incision was made in the anteroinferior quadrant using a myringotomy knife. [Effusion aspirated with a Baron suction.] A [Reuter Bobbin / Armstrong / T-tube] tympanostomy tube was placed through the myringotomy using alligator forceps. Position confirmed in the myringotomy, tube [patent].
LEFT EAR: Same procedure performed in mirror fashion.
Both ears inspected. Tubes patent and in good position. [Antibiotic otic drops instilled bilaterally at end of procedure.] Patient awakened without difficulty.
None
Middle ear fluid [sent for culture / discarded]
Minimal
Bilateral tympanostomy tubes in place
Patient taken to PACU. Discharged same day.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Recurrent acute otitis media / chronic otitis media with effusion / eustachian tube dysfunction]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Bilateral myringotomy and tympanostomy tube placement
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General inhalational (mask)
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [recurrent AOM (*** episodes in *** months, with middle ear effusion confirmed at time of assessment) / chronic bilateral OME ≥*** months with conductive hearing loss / speech delay / at-risk condition]. Bilateral middle ear effusion confirmed on pneumatic otoscopy and tympanometry. Conservative management for *** months failed. Risks including persistent perforation, tube extrusion, and otorrhea were discussed. Informed consent obtained.
FINDINGS: Bilateral tympanic membranes dull and retracted. [Amber / mucoid] effusion present bilaterally. Landmarks visible. No cholesteatoma.
DESCRIPTION OF PROCEDURE:
The patient was taken to the OR; inhalational general anesthesia administered via mask without intubation. Positioned supine. RIGHT EAR: Ear canal cleaned under operating microscope. Tympanic membrane visualized. Radial myringotomy incision made in the anteroinferior quadrant. Effusion aspirated with Baron suction. A [Reuter Bobbin / Armstrong] tympanostomy tube placed through the myringotomy with alligator forceps, confirmed patent and in good position. LEFT EAR: Same procedure performed in mirror fashion. Both tubes confirmed patent. Antibiotic otic drops instilled bilaterally. Patient awakened without difficulty.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Middle ear fluid [sent for culture / discarded]
COMPLICATIONS: None
DRAINS: Bilateral tympanostomy tubes in place
DISPOSITION: Patient taken to PACU. Discharged same day.
Signed: .ME, .MYDEGREE
.TODAYVariants
T-tube placement
For chronic Eustachian tube dysfunction. T-tubes remain for several years. Document tube type and placement site.
In-office with automated delivery device (Tula System / Hummingbird TTS)
In-office procedure with topical anesthesia. FDA-cleared for patients ≥6 months old (not adult-only). Billing differs by device — Hummingbird TTS uses 69433 + G0561 per ear; Tula System (iontophoresis) uses standalone 0583T only (cannot be combined with 69433 or G0561). Document which device was used, anesthesia adequacy, and tube placement.
Tube removal
CPT 69424. Document tube location, removal technique (alligator forceps), and tympanic membrane status.
Charting Tips
- Document tube type (short-term grommet vs. long-term T-tube — affects expected dwell time and follow-up plan)
- State fluid character (serous, mucoid, purulent) — affects postoperative antibiotic decisions
- Document that tube is patent and in correct quadrant (anteroinferior is standard)
- Document otic drops if instilled at end of case
- {'Bilateral placement': 'use modifier -50 for most payers (single line), but verify — some Medicaid/commercial payers require RT/LT modifiers on separate lines'}
- {'Per 2022 AAO-HNS CPG': 'document that MEE was confirmed at time of surgical assessment (required for recurrent AOM indication), and document OME duration (≥3 months for chronic OME indication)'}
- CPT 69424 for tube removal requires general anesthesia — do not use for office removal without GA; use an E/M code instead
- {'For in-office device procedures': 'document which delivery system was used — coding is device-specific (Hummingbird TTS = 69433+G0561; Tula System = 0583T standalone)'}
Billing Tips
- Bill 69436 for tympanostomy with tube insertion under general anesthesia (1.96 wRVU, 10-day global). This is the primary code for most pediatric bilateral tube placements.
- Bill 69433 for tympanostomy with tube insertion under local or topical anesthesia (1.53 wRVU, 10-day global). Use for in-office adult procedures or awake procedures.
- Bill 69421 for myringotomy including aspiration under general anesthesia, without tube insertion (1.74 wRVU, 10-day global). Bill 69420 for the same procedure under local/topical anesthesia (1.35 wRVU, 10-day global). Do not confuse 69420 (local) with 69421 (general anesthesia).
- For bilateral tube placement, bill 69436 with modifier -50 on a single claim line. Medicare and many commercial payers reimburse at 150% for the bilateral modifier. However, some state Medicaid and commercial payers require two separate lines with RT/LT modifiers — verify payer-specific requirements.
- 10-day global period applies to 69436, 69433, 69420, and 69421. Subsequent tube checks and audiograms are separately billable after the global period. CPT 69424 (tube removal requiring general anesthesia) has a 0-day global period.
- Adenoidectomy at the same setting: bill 42830 (primary adenoidectomy, age <12, 2.58 wRVU) or 42831 (primary adenoidectomy, age ≥12, 2.74 wRVU). For revision/secondary adenoidectomy use 42835 (<12) or 42836 (≥12). When tonsillectomy AND adenoidectomy are performed together, use the combined T&A codes 42820 (age <12, 4.11 wRVU) or 42821 (age ≥12, 4.25 wRVU) — do NOT unbundle into separate component codes.
- Tube removal requiring general anesthesia uses 69424 (0.83 wRVU, 0-day global). This code requires general anesthesia as an integral part — do not use for in-office tube removal without GA; report an E/M instead.
- In-office tube placement with automated delivery devices: coding differs by device. Hummingbird TTS: bill 69433 + add-on HCPCS G0561 (effective 1/1/2025) per ear. Tula System (iontophoresis-based): bill Category III CPT 0583T as a standalone code — do NOT combine 0583T with 69433 or G0561.
General coding reference. Verify with your institution’s billing department before submitting claims.