How To Use CPT Code 69801

CPT 69801 describes a specific procedure known as labyrinthotomy, which involves the perfusion of vestibuloactive drugs through the inner ear. This article will provide an overview of CPT 69801, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes.

1. What is CPT Code 69801?

CPT 69801 is a code used to describe a surgical procedure called labyrinthotomy. This procedure involves making an incision into the labyrinth, which is the inner ear, and then perfusing vestibuloactive drugs through the tympanic membrane. It is important to note that CPT 69801 should not be reported more than once per day and should not be reported in conjunction with certain other codes when performed on the same ear.

2. Official Description

The official description of CPT code 69801 is: ‘Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal.’ This code specifically refers to the surgical incision into the labyrinth and the instillation or perfusion of one or more drugs through the tympanic membrane.

3. Procedure

1. The provider begins by making a surgical incision into the posterior ear canal skin through the external ear opening.
2. They then reflect the skin flap and posterior tympanic membrane forward to visualize the horizontal semicircular canal.
3. Using microscopic guidance, the provider instills one or more drugs, such as anti-inflammatory steroids or aminoglycoside antibiotics, into the middle ear.
4. After the drugs have been instilled, the incision is repaired with sutures.
5. Alternatively, the provider may use a transtympanic injection with a needle to instill the drugs.

4. Qualifying circumstances

CPT 69801 is typically performed on patients who are experiencing vertigo and require treatment with vestibuloactive drugs. The procedure is performed by a provider who specializes in otolaryngology. It is important to note that CPT 69801 should not be reported more than once per day and should not be reported in conjunction with certain other codes when performed on the same ear.

5. When to use CPT code 69801

CPT code 69801 should be used when a provider performs a labyrinthotomy procedure with the perfusion of vestibuloactive drugs through the transcanal approach. It is important to follow the guidelines and not report this code more than once per day or in conjunction with certain other codes when performed on the same ear.

6. Documentation requirements

To support a claim for CPT 69801, the provider must document the following information:

• Patient’s diagnosis and the need for labyrinthotomy with drug perfusion
• Specific drugs used for perfusion
• Date of the procedure
• Details of the procedure, including the incision and drug instillation
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 69801, it is important to ensure that the procedure is performed by a qualified otolaryngologist and that the perfusion of vestibuloactive drugs is done through the transcanal approach. It should not be reported more than once per day and should not be reported in conjunction with certain other codes when performed on the same ear. Additionally, separate codes should be reported for each drug used during the procedure.

8. Historical information

CPT 69801 was added to the Current Procedural Terminology system on January 1, 1990. Since then, there have been several changes to the code, including updates to the description and the addition of notes regarding reporting limitations.

9. Examples

1. A patient with severe vertigo undergoes labyrinthotomy with the perfusion of vestibuloactive drugs through the transcanal approach to alleviate their symptoms.
2. An otolaryngologist performs a labyrinthotomy procedure on a patient with Meniere’s disease, instilling anti-inflammatory steroids into the inner ear to reduce inflammation and vertigo.
3. A patient with recurrent episodes of vertigo undergoes labyrinthotomy with the perfusion of aminoglycoside antibiotics to treat an inner ear infection.
4. An otolaryngologist performs a labyrinthotomy procedure on a patient with vestibular schwannoma, instilling vestibuloactive drugs to manage their symptoms and improve their quality of life.
5. A patient with persistent vertigo undergoes labyrinthotomy with the perfusion of vestibuloactive drugs as a last resort after other treatment options have failed to provide relief.
6. An otolaryngologist performs a labyrinthotomy procedure on a patient with labyrinthitis, instilling antibiotics into the inner ear to treat the infection and alleviate symptoms.
7. A patient with bilateral Meniere’s disease undergoes labyrinthotomy with the perfusion of vestibuloactive drugs on one ear at a time to manage their symptoms and maintain balance.
8. An otolaryngologist performs a labyrinthotomy procedure on a patient with a vestibular schwannoma, instilling vestibuloactive drugs to slow the growth of the tumor and alleviate symptoms.
9. A patient with recurrent vertigo attacks undergoes labyrinthotomy with the perfusion of aminoglycoside antibiotics to treat an inner ear infection and prevent future episodes.
10. An otolaryngologist performs a labyrinthotomy procedure on a patient with a history of head trauma, instilling vestibuloactive drugs to improve their balance and reduce dizziness.