How To Use CPT Code 69450

CPT 69450 describes a procedure called tympanolysis, transcanal, which involves the destruction of adhesions or scar tissue on the tympanic membrane to improve hearing. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69450?

CPT 69450 is a code used to describe the tympanolysis, transcanal procedure. This procedure involves the removal of scar tissue or adhesions on the tympanic membrane, also known as the eardrum, to improve hearing. It is performed by a healthcare provider using an operating microscope and a scalpel to carefully dissect and remove the scar tissue from the surface of the tympanic membrane. The provider may also use cautery if necessary and apply antibiotic drops and a dressing after the procedure.

2. Official Description

The official description of CPT code 69450 is: ‘Tympanolysis, transcanal; destruction of adhesions, membranous or fibrous.’

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The healthcare provider uses an operating microscope to visualize the tympanic membrane.
3. Using a scalpel, the provider carefully dissects and removes the scar tissue or adhesions from the surface of the tympanic membrane.
4. The provider checks for bleeding and uses cautery if necessary.
5. Antibiotic drops are instilled, and a dressing is applied to the ear.

4. Qualifying circumstances

CPT 69450 is performed on patients who have adhesions or scar tissue on their tympanic membrane that is interfering with their hearing. Adhesions are fibrous bands that typically form as a result of inflammation or injury during surgery. The procedure is performed by a healthcare provider who is trained in performing tympanolysis, transcanal procedures and has the necessary equipment, such as an operating microscope and a scalpel.

5. When to use CPT code 69450

CPT code 69450 should be used when a healthcare provider performs tympanolysis, transcanal to remove adhesions or scar tissue from the tympanic membrane. It is appropriate to use this code when the procedure is performed to improve the patient’s hearing and is medically necessary. However, it should not be used for other procedures or interventions performed on the middle ear.

6. Documentation requirements

To support a claim for CPT 69450, the healthcare provider must document the following information:

• Patient’s diagnosis and the presence of adhesions or scar tissue on the tympanic membrane
• Description of the procedure performed, including the use of an operating microscope and a scalpel
• Date of the procedure
• Any additional interventions performed, such as cautery or the application of antibiotic drops
• Any complications or post-procedure care provided
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 69450, ensure that the procedure meets the criteria for tympanolysis, transcanal and that the necessary documentation is available. It is important to use the correct CPT code for the procedure performed and to follow any specific billing guidelines provided by the payer. CPT code 69450 should not be reported with other codes unless additional procedures or interventions were performed during the same session.

8. Historical information

CPT 69450 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a history of chronic ear infections undergoes tympanolysis, transcanal to remove adhesions on the tympanic membrane.
2. A child with recurrent middle ear effusion undergoes tympanolysis, transcanal to improve hearing by removing scar tissue on the tympanic membrane.
3. A patient with conductive hearing loss undergoes tympanolysis, transcanal to address adhesions on the tympanic membrane.
4. A teenager with a history of tympanic membrane scarring undergoes tympanolysis, transcanal to improve hearing and remove scar tissue.
5. An adult with a history of ear trauma undergoes tympanolysis, transcanal to address adhesions on the tympanic membrane and improve hearing.