The opening needed for a tympanostomy tube

Read an original fictional chart, identify the supported facts, and explain your coding workflow.

Chart gym · Original fictional record

Service date: 2026-09-09 · Professional operative service; cited Medicare NCCI relationship

Use your code books and write your reasoning before opening the walkthrough. This exercise contains no real patient information.

Clinical setting

Synthetic adult with persistent left middle-ear effusion and conductive hearing symptoms undergoes left tympanostomy tube placement under local anesthesia. The operative report identifies the left ear throughout. No right-ear procedure is performed.

Procedure sequence

The clinician makes the tympanic-membrane opening needed for the tympanostomy and places the tube as documented. The opening and placement occur during the same procedure. No separate operation on the right ear is supplied.

Completion record

The report preserves both the myringotomy step and tube placement. The two names describe parts of the completed left-ear service, not proof of two independent encounters. The tube remains as intended at the end of the procedure.

Coding issue

A draft lists myringotomy in addition to the tympanostomy solely because both are named in the operative note. Apply NCCI’s inclusion, then inspect the authorized complete entry and any required anesthetic or laterality facts. Do not infer missing facts from the patient’s age.

Your coding worksheet

Identify the side and completed service.
Explain the role of the membrane opening.
Evaluate the separate myringotomy line.
Use the documented local anesthesia and left side when checking the complete current entry.

In your notebook, record the supported facts, your index route, the instructions you checked, and any missing detail that limits your answer.

Compare with the worked explanation

The completed procedure is the documented left tympanostomy with tube placement.
The myringotomy creates the opening needed for that procedure.
NCCI E.2 includes the myringotomy in the tympanostomy relationship.
The record supplies local anesthesia and left laterality. Use those facts in the current authorized book; the included myringotomy does not become an additional procedure.

Reference sections: E.2

Practice the linked chart questions