How To Use CPT Code 69505

CPT 69505 describes a surgical procedure known as modified radical mastoidectomy. This article will provide an overview of CPT code 69505, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69505?

CPT 69505 is a code used to describe a specific surgical procedure called modified radical mastoidectomy. This procedure involves the surgical resection of the mastoid part of the posterior temporal bone, with the removal of viable mucosa and disease from the mastoid cells. The goal of this procedure is to improve ventilation and aid in the drainage of infections in the middle ear.

2. Official Description

The official description of CPT code 69505 is a surgical procedure that involves the removal of viable mucosa and disease from the mastoid cells, along with the creation of a tympanic antrum opening. This procedure is performed to treat mastoid disorders, such as cholesteatosis and cholesteatoma of the mastoid.

3. Procedure

1. The surgeon performs a surgical resection of the mastoid part of the posterior temporal bone.
2. During the procedure, viable mucosa and disease are removed from the mastoid cells.
3. A tympanic antrum opening is created to improve ventilation and aid in the drainage of infections in the middle ear.
4. The surgeon may reconstruct the tympanic membrane if necessary.
5. This procedure is typically performed to treat mastoid disorders, such as cholesteatosis and cholesteatoma of the mastoid.

4. Qualifying circumstances

CPT 69505 is typically performed on patients with mastoid disorders, such as cholesteatosis and cholesteatoma of the mastoid. The procedure is indicated when other treatment options have been exhausted or when the condition poses a significant risk to the patient’s health. It is important to note that the procedure should only be performed by a qualified physician with the necessary expertise and training in mastoid surgery.

5. When to use CPT code 69505

CPT code 69505 should be used when a modified radical mastoidectomy is performed to treat mastoid disorders, such as cholesteatosis and cholesteatoma of the mastoid. It is important to ensure that the procedure meets the specific criteria outlined in the official description of the code. If the procedure does not meet these criteria, an alternative code may be more appropriate.

6. Documentation requirements

To support a claim for CPT 69505, the surgeon must document the following information:

• Patient’s diagnosis and the need for a modified radical mastoidectomy
• Details of the procedure performed, including the resection of the mastoid part of the posterior temporal bone and the removal of viable mucosa and disease from the mastoid cells
• Creation of a tympanic antrum opening and any additional steps taken during the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT 69505, it is important to ensure that the procedure meets the specific criteria outlined in the official description of the code. The surgeon should also follow any additional billing guidelines provided by the payer or relevant coding guidelines. It is important to accurately report the procedure and any associated services or supplies provided during the surgical encounter.

8. Historical information

CPT 69505 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 cholesteatoma of the mastoid undergoes a modified radical mastoidectomy to remove the disease and improve ventilation.
2. A surgeon performs a modified radical mastoidectomy on a patient with chronic mastoiditis to aid in the drainage of the infection.
3. A modified radical mastoidectomy is performed on a patient with recurrent middle ear infections to prevent further complications.
4. A patient with cholesteatosis of the mastoid undergoes a modified radical mastoidectomy to remove the abnormal growth and improve middle ear function.
5. A surgeon performs a modified radical mastoidectomy on a patient with a persistent ear discharge to address the underlying cause and improve the patient’s symptoms.
6. A modified radical mastoidectomy is performed on a patient with a mastoid abscess to drain the infection and prevent further complications.
7. A patient with a history of mastoid surgery undergoes a modified radical mastoidectomy to address recurrent disease and improve middle ear function.
8. A surgeon performs a modified radical mastoidectomy on a patient with a mastoid tumor to remove the abnormal growth and prevent further spread.
9. A modified radical mastoidectomy is performed on a patient with a congenital mastoid anomaly to correct the structural abnormality and improve middle ear function.
10. A patient with a history of chronic ear infections undergoes a modified radical mastoidectomy to address the underlying cause and prevent further complications.