How To Use CPT Code 69604

CPT 69604 describes the procedure of revision mastoidectomy resulting in tympanoplasty. 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 69604?

CPT 69604 is a code that represents the revision mastoidectomy procedure, which is performed in conjunction with tympanoplasty. This procedure is done when a previous mastoidectomy has failed to produce a dry ear, resulting in recurrent otitis media, eardrum perforation, and hearing loss. The provider revises the previous mastoidectomy to address these issues and reconstructs the eardrum.

2. Official Description

The official description of CPT code 69604 is: ‘Revision mastoidectomy; resulting in tympanoplasty.’

3. Procedure

1. The provider begins by making an incision within the ear canal or behind the ear, exposing the site of the previous mastoidectomy.
2. They then remove the posterior and superior bony canal walls down to the level of the facial nerve.
3. The provider proceeds with the reconstruction of the tympanic membrane by roughening the edges of the perforation and placing a fascia graft under or over the eardrum remnant.
4. If necessary, absorbable packing is placed in the middle ear to control bleeding, and the ear canal and mastoid cavity are packed.
5. Finally, the incision is sutured closed, and a dressing is applied.

4. Qualifying circumstances

CPT 69604 is performed when a previous mastoidectomy has resulted in a persistent wet ear, recurrent otitis media, eardrum perforation, and hearing loss. The procedure is done to revise the previous mastoidectomy and reconstruct the eardrum to address these issues.

5. When to use CPT code 69604

CPT code 69604 should be used when a revision mastoidectomy is performed in conjunction with tympanoplasty to address a failed previous mastoidectomy. It is important to accurately document the need for revision and the specific circumstances that warrant the procedure.

6. Documentation requirements

To support a claim for CPT 69604, the provider must document the following information:

• Reason for revision mastoidectomy
• Details of the previous mastoidectomy and its failure
• Incision location
• Extent of bony canal wall removal
• Technique used for tympanic membrane reconstruction
• Use of absorbable packing
• Details of the closure and dressing

7. Billing guidelines

When billing for CPT 69604, ensure that the procedure meets the criteria for revision mastoidectomy resulting in tympanoplasty. It is important to accurately document the need for revision and the specific circumstances that warrant the procedure. Report CPT 69604 separately and do not report it with other codes unless additional procedures are performed that meet the criteria for separate reporting.

8. Historical information

CPT 69604 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoes revision mastoidectomy resulting in tympanoplasty due to recurrent otitis media and eardrum perforation following a previous mastoidectomy.
2. A provider performs revision mastoidectomy resulting in tympanoplasty to address a persistent wet ear and hearing loss after a previous mastoidectomy.
3. Revision mastoidectomy resulting in tympanoplasty is performed on a patient with recurrent otitis media and residual hearing loss following a previous mastoidectomy.
4. A provider revises a previous mastoidectomy and performs tympanoplasty to address recurrent otitis media and eardrum perforation.
5. Revision mastoidectomy resulting in tympanoplasty is performed on a patient with persistent otitis media and hearing loss after a previous mastoidectomy.
6. A provider performs revision mastoidectomy resulting in tympanoplasty to address recurrent otitis media and eardrum perforation following a previous mastoidectomy.
7. Revision mastoidectomy resulting in tympanoplasty is performed on a patient with a persistent wet ear and hearing loss after a previous mastoidectomy.
8. A provider revises a previous mastoidectomy and performs tympanoplasty to address recurrent otitis media and eardrum perforation.
9. Revision mastoidectomy resulting in tympanoplasty is performed on a patient with persistent otitis media and hearing loss following a previous mastoidectomy.
10. A provider performs revision mastoidectomy resulting in tympanoplasty to address recurrent otitis media and eardrum perforation following a previous mastoidectomy.