Myringotomy and Tympanostomy Tube Placement

CPT 69436
Approach Endoscopic
Add-on / Variant CPTs
  • 69433 — Tympanostomy with local anesthesia
  • 69421 — Myringotomy, general anesthesia
  • 69424 — Removal of ventilating tube
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:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General inhalational (mask) / local
Patient supine. Bilateral ear microscopy.

Indications:

Patient presents with [recurrent AOM ([X] episodes in [X] months) / chronic OME with conductive hearing loss / failed audiogram / speech delay]. [Bilateral] middle ear effusion confirmed on [pneumatic otoscopy / tympanometry / audiogram]. Conservative management for [X months] failed. Risks including persistent perforation, tube extrusion, and otorrhea discussed. Consent obtained.

Findings:

Bilateral tympanic membranes [dull / retracted / with effusion]. [Amber / grey] effusion present bilaterally. [Fluid expressed on myringotomy: serous / mucoid / purulent.] Landmarks [visible / obscured]. No cholesteatoma.

Description of Procedure:

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.

Complications:

None

Specimens:

Middle ear fluid [sent for culture / discarded]

Estimated Blood Loss:

Minimal

Drains:

Bilateral tympanostomy tubes in place

Disposition:

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) / chronic OME with conductive hearing loss / speech delay]. 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
.TODAY
Variants

T-tube placement

For chronic Eustachian tube dysfunction. T-tubes remain for several years. Document tube type and placement site.

In-office with iontophoresis (Acclarent Tula)

Adult in-office procedure with topical anesthesia delivered by iontophoresis. CPT 69433. Document device use, 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 and manufacturer (relevant for follow-up': 'short-term vs. T-tube)'}
  • State fluid character (serous, mucoid, purulent). This affects postoperative antibiotic decisions.
  • Document that tube is patent and in correct quadrant
  • Otic drops at end of case: document if used
  • Unilateral vs. bilateral placement drives CPT selection (bilateral adds modifier -50)
Billing Tips
  • Bill 69421 for myringotomy with aspiration under general anesthesia (1.74 wRVU, 10-day global). Bill 69433 for myringotomy with tube insertion, local anesthesia (1.53 wRVU). Bill 69436 for myringotomy with tube insertion under general anesthesia (1.96 wRVU).
  • For bilateral tube placement, bill each side separately using modifier -50 (bilateral procedure) or list the code twice. Most pediatric bilateral cases use 69436 x2 with modifier -50.
  • 10-day global period: first postoperative visit is bundled for 10 days. Subsequent tube checks and audiograms are separately billable after the global period.
  • Adenoidectomy (42830 or 42835) performed at the same setting is separately billable with modifier -51. Combined T&A with tubes is a common pediatric outpatient case. Bill each component separately.
  • Tube removal (if performed in the OR) uses 69424, which is distinct from tube placement codes. Spontaneous extrusion does not generate a separate billable code.