Preoperative Diagnosis: ear infection
Postoperative Diagnosis: otitis media
Operation: Tympanostomy of the right ear
Operation Description: A 9-month-old male was diagnosed with chronic ear infections, which keep occurring and resulted with otitis media. The risks of the operation, such as infection, hearing loss, and bleeding, were discussed. The parents understood all risks and wanted to proceed with the operation. Consent was obtained.
The patient was prepped and draped in the usual sterile fashion in the operating room. General anesthesia was then administered to the patient. An incision to the tympanic membrane was completed to relieve pressure and fluid from the middle ear. A small tube was then inserted through the tympanic membrane to the middle ear to assist with pressure. The patient was in good stable condition and brought to the recovery room.
Select the appropriate CPT and ICD-10-CM codes for the anesthesiologist.

Question

Quizplus · Accepted Answer

The correct CPT code for anesthesia for tympanostomy is 00126. The physical status modifier P1 indicates a normal healthy patient. The ICD-10-CM code H66.91 is used for unspecified otitis media, right ear. The code 99100 is used for anesthesia for patients younger than 1 year.

Preoperative Diagnosis: Ear Infection