How To Use CPT Code 69620

CPT 69620 describes the surgical repair of the eardrum, specifically focusing on the drumhead and donor area. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69620?

CPT 69620 is used to describe a surgical procedure known as myringoplasty. This procedure involves the repair of the eardrum, specifically focusing on the drumhead and donor area. It is performed to close a perforation of the eardrum and prevent infection. During the surgery, the provider uses graft material, such as a piece of fascia or a plug of fat, to repair the hole in the eardrum.

2. Official Description

The official description of CPT code 69620 is: ‘Myringoplasty (surgery confined to drumhead and donor area).’ This code specifically refers to the surgical repair of the eardrum, limited to the drumhead and donor area. It does not involve any other structures or procedures related to the middle ear.

3. Procedure

1. The patient is appropriately prepped and anesthetized for the procedure.
2. The provider uses a microscope or loupes, which are magnifying lenses attached to glasses or a headband, to locate the defect in the tympanic membrane.
3. The provider prepares the tympanic membrane perforation by roughening its edges, a technique known as rimming the perforation.
4. If necessary, dissolvable packing may be placed in the middle ear.
5. The provider uses graft material, such as a fat graft plug or fascia, to repair the hole in the eardrum.
6. The incisions are sutured closed, antibiotic drops are instilled in the external auditory canal, gauze soaked in antibiotic solution is placed in the ear, and a dressing is applied.

4. Qualifying circumstances

CPT 69620 is performed on patients who have a perforation of the eardrum that requires surgical repair. The procedure is limited to the drumhead and donor area of the eardrum. It is important to note that this code does not cover other procedures related to the middle ear or the repair of the tympanic membrane with or without patch site preparation.

5. When to use CPT code 69620

CPT code 69620 should be used when a provider performs a myringoplasty, specifically focusing on the drumhead and donor area of the eardrum. It is appropriate to use this code when the procedure is performed to close a perforation of the eardrum and prevent infection. However, it should not be used for other procedures related to the middle ear or the repair of the tympanic membrane with or without patch site preparation.

6. Documentation requirements

To support a claim for CPT 69620, the provider must document the following information:

• Patient’s diagnosis indicating the need for myringoplasty
• Details of the procedure, including the use of graft material and any additional techniques performed
• Date of the procedure
• Any complications or unexpected findings
• Post-operative care instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 69620, ensure that the procedure performed is limited to the drumhead and donor area of the eardrum. It is important to note that this code should not be reported with other codes related to the repair of the tympanic membrane or procedures involving the middle ear. Additionally, it is crucial to follow any specific guidelines provided by the payer regarding the use of this code.

8. Historical information

CPT 69620 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 myringoplasty to repair a perforation in the eardrum caused by trauma.
2. A child with chronic ear infections undergoes myringoplasty to prevent further infections and improve hearing.
3. A patient with a history of repeated ear infections and hearing loss undergoes myringoplasty to repair a perforation in the eardrum.
4. A provider performs myringoplasty on a patient with a persistent perforation in the eardrum following a previous surgery.
5. A myringoplasty is performed on a patient with a perforation in the eardrum caused by barotrauma during scuba diving.
6. A patient undergoes myringoplasty to repair a perforation in the eardrum caused by chronic middle ear infections.
7. A provider performs myringoplasty on a patient with a perforation in the eardrum caused by a foreign object insertion.
8. A child with a congenital perforation in the eardrum undergoes myringoplasty to improve hearing and prevent infections.
9. A patient with a history of recurrent ear infections and hearing loss undergoes myringoplasty to repair a perforation in the eardrum.
10. A myringoplasty is performed on a patient with a traumatic perforation in the eardrum caused by a car accident.