How To Use CPT Code 69641

CPT 69641 describes the procedure known as tympanoplasty with mastoidectomy, which involves the reconstruction of the tympanic membrane (eardrum) and the removal of all or a portion of the mastoid. 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 69641?

CPT 69641 is used to describe a surgical procedure called tympanoplasty with mastoidectomy. This procedure involves the reconstruction of the tympanic membrane to repair a perforation and the removal of all or part of the mastoid, which is the bony structure behind the ear. It is important to note that this procedure does not include the reconstruction of the ossicular chain, which refers to the tiny bones in the middle ear responsible for transmitting sound.

2. Official Description

The official description of CPT code 69641 is: ‘Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction.’

3. Procedure

1. During the procedure, the healthcare provider begins by making an incision in the ear canal to access the middle ear.
2. A posterior tympanomeatal flap is created and reflected forward to provide better access to the middle ear.
3. An incision is made behind the ear (postauricular or intra-auricular) to access the mastoid.
4. The provider removes the mastoid cortex and mastoid air cells, creating a cavity known as the mastoid cavity or mastoid antrum.
5. The edges of the tympanic membrane are roughened, a process called rimming the perforation.
6. The eardrum is reflected forward, and any adhesions, skin debris, or cholesteatoma (benign tumor) in the middle ear are removed.
7. If necessary, the provider may reconstruct the ear canal using plastic repair techniques.
8. A graft, such as fascia or other tissue, is harvested to repair the tear in the eardrum.
9. The graft is placed on top of or beneath the eardrum, and packing may be used to support it.
10. The skin in the ear canal is repositioned, and the canal is packed to hold the skin in place.
11. Any exterior incisions are sutured closed, and a dressing is applied.

4. Qualifying circumstances

CPT 69641 is typically performed on patients with a perforated tympanic membrane and mastoid-related issues. It is important to note that this procedure does not involve the reconstruction of the ossicular chain. The provider must assess the patient’s condition and determine the need for tympanoplasty with mastoidectomy. The procedure is performed by a qualified healthcare professional with the necessary expertise in middle ear surgery.

5. When to use CPT code 69641

CPT code 69641 should be used when a tympanoplasty with mastoidectomy is performed without the reconstruction of the ossicular chain. It is important to accurately document the procedure performed to ensure proper coding and billing.

6. Documentation requirements

When reporting CPT code 69641, the healthcare provider must document the following information:

• Patient’s diagnosis indicating the need for tympanoplasty with mastoidectomy
• Details of the procedure performed, including the specific techniques used
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures or interventions performed during the same session
• Any complications or unexpected findings
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 69641, it is important to ensure that the procedure performed aligns with the description of the code. The provider should be qualified and experienced in performing tympanoplasty with mastoidectomy. It is also essential to follow any specific billing guidelines provided by the payer or coding guidelines. CPT code 69641 should not be reported with codes 69635, 69643, or 69645, as they represent different procedures.

8. Historical information

CPT code 69641 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 tympanoplasty with mastoidectomy to repair a perforated eardrum and remove infected mastoid tissue.
2. A healthcare provider performs tympanoplasty with mastoidectomy on a patient with chronic ear infections and a history of mastoiditis.
3. A child with a congenital malformation of the ear undergoes tympanoplasty with mastoidectomy to improve hearing and prevent further complications.
4. A patient with a traumatic injury to the ear requires tympanoplasty with mastoidectomy to repair the damaged structures.
5. A healthcare provider performs tympanoplasty with mastoidectomy on a patient with cholesteatoma, a benign tumor, in the middle ear.
6. An adult with a history of recurrent ear infections undergoes tympanoplasty with mastoidectomy to address the underlying issues and improve hearing.
7. A patient with a perforated eardrum and chronic mastoiditis undergoes tympanoplasty with mastoidectomy to resolve the infections and restore normal ear function.
8. A healthcare provider performs tympanoplasty with mastoidectomy on a patient with a history of ear trauma and persistent hearing loss.