2025 CPT code 69420
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Surgical Procedures on the Auditory System Surgery Feed
Myringotomy with aspiration and/or eustachian tube inflation.
Modifiers may be applicable depending on the circumstances of the procedure, such as 50 (bilateral procedure), 51 (multiple procedures), or 59 (distinct procedural service).Always consult current modifier guidelines.
Medical necessity for a myringotomy is typically established when conservative management (e.g., antibiotics, decongestants) fails to resolve symptoms of otitis media or Eustachian tube dysfunction, or when there is evidence of significant hearing loss or complications from the condition.
The otolaryngologist (ENT doctor) is clinically responsible for performing the myringotomy, including pre-operative assessment, procedure execution, and post-operative care.This may include obtaining informed consent, preparing the patient, administering local anesthesia, making the incision, aspirating fluid (if necessary), inflating the Eustachian tube (if indicated), and providing post-operative instructions.
In simple words: The doctor makes a tiny cut in the eardrum to drain fluid and/or blow air into the Eustachian tube (the tube connecting the middle ear to the back of the nose) to help clear a middle ear infection or problem with the tube itself.
This CPT code 69420 represents a myringotomy, which involves creating a small incision in the tympanic membrane (eardrum).This procedure may include aspiration of fluid from the middle ear and/or inflation of the Eustachian tube using a tube or catheter inserted through the tympanotomy. The procedure is performed to treat Eustachian tube dysfunction or otitis media.It is typically done under local or topical anesthesia.
Example 1: A 5-year-old child presents with chronic otitis media with effusion (OME) and significant hearing loss.A myringotomy with aspiration is performed to drain the fluid, improving hearing and reducing the risk of further infection.The procedure is performed under general anesthesia., An adult patient with Eustachian tube dysfunction experiences recurrent ear infections and ear pain.A myringotomy with Eustachian tube inflation is performed under local anesthesia to alleviate symptoms and improve tube function., A patient presents with acute otitis media that is unresponsive to medical management. A myringotomy with aspiration and culture of the fluid is performed to identify the causative pathogen and guide targeted antibiotic therapy.
Pre-operative documentation should include a thorough history and physical exam, audiometry results, tympanometry findings, and informed consent. Intraoperative documentation should specify the technique used, the amount and type of fluid aspirated (if any), and the success of Eustachian tube inflation (if performed). Post-operative documentation should include the patient's response to the procedure and any complications.
** This code should not be used if a tympanostomy tube is placed. In such cases, use the appropriate tympanostomy code(s).Always ensure proper documentation to support the medical necessity of the procedure.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: This information is not available in the provided text.Consult the current CPT manual and your payer's fee schedule for RVU values.
- Global Days : This information is not provided.Refer to your payer's guidelines for global period details.
- Payment Status: Active
- Modifier TC rule: This information is not explicitly available.Consult the CPT manual and your payer's guidelines.
- Fee Schedule : This information is not available in the source data.Consult historical CPT fee schedules.
- Specialties:Otolaryngology
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department