How To Use CPT Code 69601

CPT 69601 describes a procedure known as revision mastoidectomy, which involves the complete removal of the mastoid bone. This article will provide an overview of CPT 69601, 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 69601?

CPT 69601 is a code used to describe the revision mastoidectomy procedure. This procedure is performed when a previous mastoidectomy has failed to produce a dry ear, resulting in recurrent otitis media, pus accumulation, eardrum perforation, and hearing loss. During the revision mastoidectomy, the provider removes any diseased mastoid mucosa or cholesteatoma present. It is important to note that CPT 69601 specifically refers to a complete mastoidectomy.

2. Official Description

The official description of CPT code 69601 is: ‘Revision mastoidectomy; resulting in complete mastoidectomy.’

3. Procedure

1. The provider begins by making an incision behind the ear and accessing the mastoid cavity.
2. They then drill out the mastoid cavity, exposing the mastoid sinus posteriorly and the tegmen superiorly.
3. The posterior ear canal wall is left intact, and the provider ensures visibility of the semicircular canal and part of the incus.
4. Any diseased tissue from the mastoid and any cholesteatoma present are removed.
5. Bleeding is controlled, and the incision is sutured closed. A temporary drain may be placed if necessary, and a dressing is applied.

4. Qualifying circumstances

Revision mastoidectomy is performed when a previous mastoidectomy has not been successful in achieving a dry ear. This procedure is indicated for patients experiencing recurrent otitis media, pus accumulation, eardrum perforation, and hearing loss. The presence of acute or recurrent cholesteatoma may also warrant a revision mastoidectomy. It is important to note that CPT 69601 specifically refers to a complete mastoidectomy.

5. When to use CPT code 69601

CPT code 69601 should be used when a provider performs a revision mastoidectomy resulting in a complete mastoidectomy. It is important to ensure that the procedure meets the specific criteria outlined in the official description. If the procedure does not involve a complete mastoidectomy, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 69601, the provider must document the following information:

• The reason for the revision mastoidectomy and the failure of the previous procedure
• Details of the procedure performed, including the specific steps taken
• Any complications encountered during the procedure
• Post-operative care instructions and any follow-up appointments scheduled
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 69601, it is important to ensure that the procedure meets the criteria outlined in the official description. The provider should also follow any additional guidelines provided by the payer. It is important to note that CPT 69601 should not be reported if other specific codes, such as CPT 69602, 69603, or 69604, are more appropriate for the procedure performed. It is also important to consider any applicable modifiers that may be required for accurate billing.

8. Historical information

CPT 69601 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 undergoes a revision mastoidectomy due to recurrent otitis media and accumulation of pus in the ear.
2. A previous mastoidectomy has resulted in eardrum perforation and residual hearing loss, leading to the need for a revision mastoidectomy.
3. A patient with acute cholesteatoma undergoes a revision mastoidectomy to remove the diseased tissue.
4. A revision mastoidectomy is performed on a patient with recurrent cholesteatoma to prevent further complications.
5. A previous mastoidectomy has failed to produce a dry ear, resulting in the need for a revision mastoidectomy to address the ongoing issues.
6. A patient experiences recurrent otitis media and hearing loss following a previous mastoidectomy, necessitating a revision mastoidectomy.
7. A revision mastoidectomy is performed on a patient with chronic otitis media and persistent eardrum perforation.
8. A patient with a history of cholesteatoma undergoes a revision mastoidectomy to remove any remaining diseased tissue.
9. A previous mastoidectomy has resulted in recurrent otitis media and accumulation of pus, leading to the need for a revision mastoidectomy.
10. A revision mastoidectomy is performed on a patient with chronic otitis media and residual hearing loss.