2025 CPT code 69421
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Auditory System Surgery Feed
Myringotomy with aspiration and/or Eustachian tube inflation under general anesthesia.
Modifiers may be applicable depending on the circumstances of the procedure.Refer to the most recent CPT and payer guidelines.
Medical necessity is established by documentation of recurrent or chronic otitis media with effusion, Eustachian tube dysfunction, or other conditions requiring myringotomy with aspiration and/or Eustachian tube inflation to improve hearing or treat infection.
The otolaryngologist or surgeon performs the procedure.Preoperative assessment, procedural execution under general anesthesia, and postoperative care are all part of the clinical responsibility.
In simple words: The doctor makes a small cut in the eardrum while the patient is completely asleep (under general anesthesia).They may remove fluid from the middle ear and/or gently inflate the Eustachian tube to improve hearing and treat ear infections.
This CPT code, 69421, represents a myringotomy (incision of the tympanic membrane or eardrum) procedure performed under general anesthesia.The procedure may include aspiration of fluid from the middle ear and/or inflation of the Eustachian tube via a catheter or tube inserted through the tympanotomy site. This is done to treat Eustachian tube dysfunction or otitis media.
Example 1: A 5-year-old child presents with recurrent otitis media with effusion (fluid in the middle ear) and hearing loss.A myringotomy with aspiration and Eustachian tube inflation under general anesthesia is performed to relieve pressure and improve hearing., An adult patient suffers from chronic Eustachian tube dysfunction.A myringotomy with Eustachian tube inflation is performed under general anesthesia to alleviate symptoms., A patient with acute otitis media and significant middle ear effusion undergoes a myringotomy with aspiration and Eustachian tube inflation under general anesthesia to drain fluid and reduce inflammation.
* Detailed history and physical examination noting symptoms of otitis media or Eustachian tube dysfunction.* Preoperative assessment including hearing tests (audiometry).* Operative report detailing the procedure, including whether aspiration was performed, and whether Eustachian tube inflation was done.* Postoperative instructions given to the patient.* Any complications encountered during or after the surgery.
** This procedure is often performed on pediatric patients.Always ensure thorough documentation to support the medical necessity of the procedure.
- Revenue Code: P5E (Ambulatory Procedures - Other)
- RVU: This information is not available in the provided source.Consult the CMS national physician fee schedule or other relevant payer resources for RVU values.
- Global Days : The global period for this procedure is not specified in the sources. Refer to payer-specific guidelines for determining the appropriate global period.
- Payment Status: Active
- Modifier TC rule: The TC modifier is not applicable to this code as it describes a complete procedure.
- Fee Schedule : Historical fee schedule data is not provided. Consult your payer’s fee schedule.
- Specialties:Otolaryngology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center