How To Use CPT Code 69725

CPT 69725 describes a surgical procedure that involves decompression of the intratemporal facial nerve, including the area medial to the geniculate ganglion. This article will provide an overview of CPT code 69725, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69725?

CPT 69725 is a code used to describe a surgical procedure that involves decompression of the intratemporal facial nerve, specifically including the area medial to the geniculate ganglion. This procedure is typically performed in the middle ear and aims to alleviate pressure on the facial nerve, which can help improve facial muscle function and relieve associated symptoms.

2. Official Description

The official description of CPT code 69725 is: ‘Decompression facial nerve, intratemporal; including medial to geniculate ganglion.’

3. Procedure

1. The patient is positioned supine on the operating table with the affected temporal bone facing upwards.
2. A trap-door incision is made, and the skin flap is elevated to expose the temporal muscle.
3. The temporal root of the zygoma is exposed, and further elevation is performed until the petrous ridge is identified.
4. The physician then drills until the yellow bone of the otic capsule (inner ear) is identified.
5. Using a disposable microscalpel, the intratemporal facial nerve is decompressed, including the area medial to the geniculate ganglion.
6. A piece of the bone flap is used to cover any defects created during the decompression.

4. Qualifying circumstances

CPT 69725 is typically performed on patients who require decompression of the intratemporal facial nerve, specifically including the area medial to the geniculate ganglion. This procedure is indicated for individuals experiencing facial nerve compression-related symptoms, such as facial muscle weakness or paralysis. It is important to note that this procedure is performed in the middle ear and requires a skilled physician with expertise in otolaryngology.

5. When to use CPT code 69725

CPT code 69725 should be used when a physician performs a decompression procedure on the intratemporal facial nerve, including the area medial to the geniculate ganglion. This code accurately represents the specific surgical intervention and should be used for reporting purposes.

6. Documentation requirements

To support a claim for CPT code 69725, the physician must document the following information:

• Patient’s diagnosis and symptoms indicating the need for decompression of the intratemporal facial nerve
• Details of the surgical procedure, including the specific steps performed
• Date of the procedure
• Any complications or unexpected findings during the surgery
• Post-operative care instructions and follow-up plans
• Physician’s signature

7. Billing guidelines

When billing for CPT code 69725, it is important to ensure that the procedure performed aligns with the specific requirements outlined in the code description. Additionally, it is crucial to follow any applicable payer guidelines and modifiers for accurate reimbursement. It is recommended to review the payer’s policies and consult the current coding guidelines to ensure proper billing practices.

8. Historical information

CPT code 69725 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or revisions to the code since its initial inclusion.

9. Examples

1. A patient with facial muscle weakness undergoes decompression of the intratemporal facial nerve, including the area medial to the geniculate ganglion, to alleviate pressure and improve muscle function.
2. A middle-aged individual presents with facial paralysis and undergoes a surgical procedure involving decompression of the intratemporal facial nerve, including the area medial to the geniculate ganglion, to restore facial muscle function.
3. A patient with a history of chronic facial nerve compression-related symptoms undergoes decompression of the intratemporal facial nerve, including the area medial to the geniculate ganglion, to alleviate ongoing facial muscle weakness.
4. An individual experiencing facial muscle weakness and associated pain undergoes a surgical intervention involving decompression of the intratemporal facial nerve, including the area medial to the geniculate ganglion, to improve their quality of life.
5. A patient with facial nerve compression-related symptoms, such as difficulty in facial expressions, undergoes a decompression procedure on the intratemporal facial nerve, including the area medial to the geniculate ganglion, to restore normal muscle function.