How To Use CPT Code 69661

CPT 69661 describes a surgical procedure that involves the removal of the stapes bone in the middle ear, known as a stapedectomy, or the creation of an opening in the bone, known as a stapedotomy. This procedure is performed to reestablish ossicular continuity, increase mobility of the stapes, and improve hearing. In this article, we will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69661?

CPT 69661 is a surgical code that represents the removal of the stapes bone in the middle ear, also known as a stapedectomy, or the creation of an opening in the bone, known as a stapedotomy. This procedure is performed to reestablish ossicular continuity, increase mobility of the stapes, and improve hearing. It is important to note that this code specifically includes the use of a footplate drill out.

2. Official Description

The official description of CPT code 69661 is: ‘Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out.’

3. Procedure

1. The surgeon begins by creating an incision in the posterior ear canal or may approach the area with a postauricular incision.
2. Using microscopic visualization, the surgeon moves the skin flap and posterior eardrum forward.
3. If necessary, a portion of the bony canal may be removed using a curette or drill.
4. The surgeon identifies and moves the ossicular chain, separating the stapes from the incus.
5. The stapes bone is then removed, either through a stapedectomy or a stapedotomy.
6. A drill or laser is used to create an opening in the thickened footplate.
7. A prosthetic replacement is placed on the incus, and a piece of fascia, vein, perichondrium, or fat may be added to help stabilize the prosthesis.
8. The canal skin flap and eardrum are repositioned, and the ear canal is packed.

4. Qualifying circumstances

CPT 69661 is performed on patients who require the reestablishment of ossicular continuity and improved hearing. This procedure is typically indicated for individuals with hearing loss caused by abnormalities in the stapes bone. It is important to note that the use of a footplate drill out is included in this code.

5. When to use CPT code 69661

CPT code 69661 should be used when a surgeon performs a stapedectomy or stapedotomy with a footplate drill out to reestablish ossicular continuity and improve hearing. It is important to ensure that the procedure performed aligns with the specific details outlined in the code description.

6. Documentation requirements

When documenting a claim for CPT 69661, the surgeon should include the following information:

• Patient’s diagnosis and the need for the stapedectomy or stapedotomy
• Details of the procedure performed, including the use of a footplate drill out
• Incision approach (posterior ear canal or postauricular)
• Specific techniques used during the procedure, such as curette or drill
• Placement of the prosthetic replacement and any additional materials used
• Repositioning of the canal skin flap and eardrum
• Packing of the ear canal

7. Billing guidelines

When billing for CPT 69661, it is important to ensure that the procedure performed aligns with the specific details outlined in the code description. Additionally, consider the following guidelines:

• Do not report CPT 69661 if a footplate drill out was not performed.
• Be aware of any bundling or unbundling issues with other related codes.
• Review any specific payer guidelines or requirements for reporting CPT 69661.

8. Historical information

CPT 69661 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 with conductive hearing loss undergoes a stapedectomy with footplate drill out to reestablish ossicular continuity and improve hearing.
2. A surgeon performs a stapedotomy with footplate drill out on a patient with otosclerosis to improve their hearing.
3. An individual with a history of chronic ear infections undergoes a stapedectomy with footplate drill out to address their hearing loss.
4. A patient with a congenital abnormality of the stapes bone undergoes a stapedotomy with footplate drill out to improve their hearing.
5. A surgeon performs a stapedectomy with footplate drill out on a patient with a traumatic injury to the middle ear to restore ossicular continuity and improve hearing.
6. An individual with a history of recurrent ear infections undergoes a stapedotomy with footplate drill out to address their hearing loss.
7. A patient with otosclerosis undergoes a stapedectomy with footplate drill out to improve their hearing.
8. A surgeon performs a stapedotomy with footplate drill out on a patient with a congenital abnormality of the middle ear to restore ossicular continuity and improve hearing.
9. An individual with a history of chronic ear infections undergoes a stapedectomy with footplate drill out to address their hearing loss.
10. A patient with a traumatic injury to the middle ear undergoes a stapedotomy with footplate drill out to restore ossicular continuity and improve hearing.