How To Use CPT Code 69603

CPT 69603 describes the procedure of revision mastoidectomy resulting in radical mastoidectomy. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69603?

CPT 69603 is used to describe the revision mastoidectomy procedure that results in a radical mastoidectomy. This surgical procedure involves the excision of the ossicles, eustachian tube and middle ear mucosa, granulation tissue, and cholesteatoma. The provider may also reconstruct the ear canal if necessary. The revision mastoidectomy is performed when a previous procedure failed to produce a dry ear, leading to recurrent otitis media, pus accumulation, eardrum perforation, and hearing loss.

2. Official Description

The official description of CPT code 69603 is: ‘Revision mastoidectomy; resulting in radical mastoidectomy.’

3. Procedure

1. The provider begins by making an incision within the ear canal or behind the ear, dissecting tissues down to the site of the previous mastoidectomy.
2. Posterior and superior bony canal walls are taken down to the level of the facial nerve.
3. The ossicles are removed, with an attempt to spare the stapes to preserve some hearing.
4. Eustachian tube orifice mucosa, middle ear mucosa, granulation tissue, and cholesteatoma are resected.
5. The middle ear and mastoid cavity are exposed through the ear canal, and a meatoplasty may be performed to reconstruct the ear canal if needed.
6. Absorbable packing is placed in the ear canal to control bleeding, and the wound is sutured closed.
7. A dressing is applied to the surgical site.

4. Qualifying circumstances

CPT 69603 is performed when a previous complete or modified radical mastoidectomy needs to be revised. The revision is necessary due to the failure of the initial procedure to produce a dry ear, resulting in recurrent otitis media, pus accumulation, eardrum perforation, and hearing loss. The procedure is performed by a qualified provider who has the expertise to perform a radical mastoidectomy.

5. When to use CPT code 69603

CPT code 69603 should be used when a revision mastoidectomy is performed, resulting in a radical mastoidectomy. It is important to accurately document the need for revision and the specific details of the procedure to support the use of this code.

6. Documentation requirements

To support a claim for CPT 69603, the following documentation is required:

• Explanation of the need for revision mastoidectomy
• Details of the previous mastoidectomy procedure
• Specific steps taken during the revision mastoidectomy
• Description of the excised tissues and structures
• Documentation of any reconstruction performed
• Information on any complications or unexpected findings
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 69603, ensure that the procedure performed is a revision mastoidectomy resulting in a radical mastoidectomy. It is important to accurately document the need for revision and the specific details of the procedure to support the use of this code. Additionally, be aware of any specific payer guidelines or requirements for reporting this code.

8. Historical information

CPT 69603 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 resulting in a radical mastoidectomy due to recurrent otitis media and hearing loss.
2. A previous mastoidectomy procedure fails to produce a dry ear, leading to eardrum perforation and pus accumulation, requiring a revision mastoidectomy resulting in a radical mastoidectomy.
3. A patient experiences cholesteatoma recurrence after a previous mastoidectomy, necessitating a revision mastoidectomy resulting in a radical mastoidectomy.
4. A revision mastoidectomy resulting in a radical mastoidectomy is performed on a patient with persistent middle ear infection and granulation tissue.
5. A previous mastoidectomy procedure results in residual cholesteatoma, requiring a revision mastoidectomy resulting in a radical mastoidectomy.
6. A patient undergoes a revision mastoidectomy resulting in a radical mastoidectomy to address recurrent otitis media and hearing loss.
7. A revision mastoidectomy resulting in a radical mastoidectomy is performed on a patient with persistent ear drainage and cholesteatoma.
8. A previous mastoidectomy procedure fails to resolve the patient’s chronic ear infection, leading to a revision mastoidectomy resulting in a radical mastoidectomy.
9. A revision mastoidectomy resulting in a radical mastoidectomy is performed on a patient with recurrent ear infections and hearing loss.
10. A patient undergoes a revision mastoidectomy resulting in a radical mastoidectomy to address persistent cholesteatoma and eardrum perforation.