How To Use CPT Code 69806

CPT 69806 describes a surgical procedure performed to open and drain the endolymphatic sac, with the placement of a shunt for continued pressure relief. 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 69806?

CPT 69806 is a code used to describe a surgical procedure that involves opening and draining the endolymphatic sac, along with the placement of a shunt. This procedure is performed to relieve pressure in the inner ear and treat Ménière’s disease, a condition characterized by severe dizziness, tinnitus, hearing loss, and a feeling of pressure or pain in the inner ear.

2. Official Description

The official description of CPT code 69806 is: ‘Endolymphatic sac operation; with shunt.’

3. Procedure

1. The patient is positioned supine with the head turned to one side and the affected ear uppermost.
2. An incision is made to expose the mastoid bone.
3. The mastoid is opened, and the bony cover of the sigmoid sinus is removed.
4. The provider carefully skeletonizes the sigmoid sinus, posterior fossa dura, and posterior semicircular canal.
5. The thin bone covering the posterior fossa dura and sigmoid sinus is removed.
6. The endolymphatic sac is exposed, and an incision is made to drain the sac.
7. A tube is placed between the endolymphatic sac and the mastoid cavity of the middle ear to provide continued relief of pressure.

4. Qualifying circumstances

CPT 69806 is performed on patients with Ménière’s disease who require pressure relief in the inner ear. The procedure involves opening and draining the endolymphatic sac, along with the placement of a shunt. It is important to note that there are multiple techniques for performing this surgery, and the described procedure is just one example.

5. When to use CPT code 69806

CPT code 69806 should be used when a surgical procedure is performed to open and drain the endolymphatic sac, with the placement of a shunt, for the treatment of Ménière’s disease. It is important to ensure that the procedure meets the specific requirements outlined in the code description.

6. Documentation requirements

To support a claim for CPT 69806, the following documentation is required:

• Patient’s diagnosis of Ménière’s disease
• Description of the procedure performed, including the opening and draining of the endolymphatic sac and the placement of a shunt
• Date of the procedure
• Details of the surgical approach and technique used
• Any additional relevant information or findings
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 69806, ensure that the procedure meets the specific requirements outlined in the code description. It is important to accurately document and code the procedure to avoid any billing errors or denials. Additionally, consider any applicable modifiers or additional codes that may be necessary to accurately represent the services provided.

8. Historical information

CPT 69806 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 Ménière’s disease undergoes a surgical procedure to open and drain the endolymphatic sac, with the placement of a shunt, to relieve pressure in the inner ear.
2. A provider performs an endolymphatic sac operation with a shunt for a patient experiencing severe dizziness, tinnitus, and hearing loss due to Ménière’s disease.
3. During the procedure, the provider carefully exposes the endolymphatic sac, makes an incision to drain it, and places a shunt for continued pressure relief.
4. A surgical team performs an endolymphatic sac operation with a shunt to alleviate the symptoms of Ménière’s disease in a patient.
5. After the procedure, the patient experiences a reduction in dizziness and tinnitus, indicating successful pressure relief in the inner ear.
6. A surgeon performs an endolymphatic sac operation with a shunt to treat a patient with Ménière’s disease, improving their quality of life.
7. During the surgery, the provider removes the bony cover of the sigmoid sinus and places a tube between the endolymphatic sac and the mastoid cavity for continued relief of pressure.
8. A patient with Ménière’s disease undergoes an endolymphatic sac operation with a shunt to alleviate the symptoms of the condition.
9. The surgical procedure involves opening and draining the endolymphatic sac, along with the placement of a shunt, to provide pressure relief in the inner ear.
10. After the surgery, the patient experiences a decrease in the frequency and severity of vertigo attacks, indicating the success of the procedure.