ICD-10-CM for Bilateral Cerumen Impactions

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September 10, 2015

Question:  

I noticed that the ICD-10 codes for many ear conditions are specific for right, left and bilateral. But what if I am billing for a bilateral procedure, such as tympanostomy tubes? Should I use the right and left codes, or should I use the bilateral code?

Answer:

Good question! If a bilateral code exists and the disorder is documented as bilateral, then the bilateral code should be used. You would not use the individual right and left codes just because you are billing bilateral procedures even if you are line-item billing the procedure (i.e., 69436 and 69436-50).

*This response is based on the best information available as of 09/10/15.

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