How To Use CPT Code 69511

CPT 69511 describes a radical mastoidectomy procedure, which involves the resection of the entire mastoid part of the posterior temporal bone. 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 69511?

CPT 69511 is a code used to describe a radical mastoidectomy procedure. It involves the removal of viable mucosa and disease from the mastoid cells, along with the creation of a tympanic antrum opening to improve ventilation. This procedure is typically performed to aid in the drainage of an infection in the middle ear.

2. Official Description

The official description of CPT code 69511 is: ‘Mastoidectomy; radical.’ This procedure involves the resection of the entire mastoid part of the posterior temporal bone. It is important to note that for skin grafts, a different set of codes should be used (15004 et seq), and for mastoidectomy cavity debridement, other codes should be used (69220, 69222).

3. Procedure

A radical mastoidectomy is performed by a physician to remove the entire mastoid part of the posterior temporal bone. This procedure is typically done in cases of extensive cholesteatoma of the mastoid. The physician also removes the tympanum and middle ear components, although the stapes may be left out to retain minimum audibility. The goal of the procedure is to improve ventilation and aid in the drainage of infections in the middle ear.

4. Qualifying circumstances

A radical mastoidectomy is typically performed when there is a need to remove viable mucosa and disease from the mastoid cells. It is often done in cases of extensive cholesteatoma of the mastoid, where there is a significant infection or disease present. The procedure is performed by a physician and may be necessary to improve ventilation and aid in the drainage of infections in the middle ear.

5. When to use CPT code 69511

CPT code 69511 should be used when a radical mastoidectomy procedure is performed. This code is appropriate when the physician removes the entire mastoid part of the posterior temporal bone and also removes the tympanum and middle ear components. It is important to note that this code should not be used for skin grafts or mastoidectomy cavity debridement, as separate codes exist for those procedures.

6. Documentation requirements

To support a claim for CPT code 69511, the physician must document the following information:

• Reason for performing the radical mastoidectomy
• Details of the procedure, including the removal of the mastoid part of the posterior temporal bone and the tympanum and middle ear components
• Any complications or additional procedures performed during the surgery
• Signature of the performing physician

7. Billing guidelines

When billing for CPT code 69511, ensure that the procedure performed meets the criteria for a radical mastoidectomy. It is important to use the correct code for skin grafts (15004 et seq) or mastoidectomy cavity debridement (69220, 69222) if those procedures are performed. Additionally, consider any applicable modifiers or additional codes that may be necessary to accurately report the procedure.

8. Historical information

CPT code 69511 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. Similar codes to CPT 69511

Five similar codes to CPT 69511 include:

• CPT 69501: Tympanotomy (requiring mastoidectomy or tympanoplasty repair); with exploration of middle ear
• CPT 69502: Tympanotomy (requiring mastoidectomy or tympanoplasty repair); with removal of lesion
• CPT 69505: Tympanotomy (requiring mastoidectomy or tympanoplasty repair); with ossicular chain reconstruction
• CPT 69535: Tympanoplasty without mastoidectomy (including canalplasty, atticotomy, and/or middle ear surgery)
• CPT 69540: Tympanoplasty with mastoidectomy (including canalplasty, atticotomy, and/or middle ear surgery)

9. Examples

1. A physician performing a radical mastoidectomy to remove extensive cholesteatoma of the mastoid in a patient with recurrent middle ear infections.
2. A surgeon performing a radical mastoidectomy to improve ventilation and aid in the drainage of an infection in the middle ear of a patient with chronic otitis media.
3. A specialist performing a radical mastoidectomy to remove viable mucosa and disease from the mastoid cells in a patient with mastoiditis.
4. A surgeon performing a radical mastoidectomy to treat a patient with a large cholesteatoma that has eroded the mastoid bone.
5. A physician performing a radical mastoidectomy to remove infected tissue and improve ventilation in a patient with a history of recurrent ear infections.
6. A specialist performing a radical mastoidectomy to remove diseased tissue and improve drainage in a patient with chronic otitis media.
7. A surgeon performing a radical mastoidectomy to remove extensive cholesteatoma and improve ventilation in a patient with a history of ear infections.
8. A physician performing a radical mastoidectomy to remove infected tissue and improve ventilation in a patient with mastoiditis.
9. A specialist performing a radical mastoidectomy to remove diseased tissue and improve drainage in a patient with a large cholesteatoma.
10. A surgeon performing a radical mastoidectomy to remove extensive cholesteatoma and improve ventilation in a patient with chronic otitis media.