How To Use CPT Code 69910

CPT 69910 describes the excision procedure on the inner ear known as labyrinthectomy with mastoidectomy. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 69910?

CPT 69910 is used to describe a surgical procedure that involves the excision of the labyrinth, which is the part of the inner ear responsible for both hearing and balance. This procedure is performed to treat patients who have no hearing in one ear and are experiencing vertigo or dizziness as a result. The procedure includes the destruction of the semicircular canals, the utricle, and the saccule to remove the diseased labyrinth from the remaining vestibular system.

2. Official Description

The official description of CPT code 69910 is: ‘Labyrinthectomy; with mastoidectomy.’

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. A transmastoid approach, also known as a postauricular incision, is made behind the outer projecting portion of the ear.
3. The provider performs a mastoidectomy using a burr drill, operating microscope, and suction irrigation to drill out the mastoid cavity.
4. The mastoidectomy is extended, and the three semicircular canals, along with the saccule and utricle, are removed with the drill.
5. Once the procedure is complete, the incision is sutured, and a dressing is applied.

4. Qualifying circumstances

CPT 69910 is performed on patients who have no hearing in one ear and are experiencing vertigo or dizziness. The procedure is intended to remove the diseased labyrinth from the vestibular system to alleviate these symptoms. It is important to note that this procedure should only be performed by a qualified healthcare professional with the necessary expertise and training.

5. When to use CPT code 69910

CPT code 69910 should be used when a labyrinthectomy with mastoidectomy is performed to treat a patient with no hearing in one ear and experiencing vertigo or dizziness. It is important to ensure that the procedure is medically necessary and appropriate for the patient’s condition before using this code.

6. Documentation requirements

To support a claim for CPT 69910, the healthcare professional must document the following information:

• Patient’s diagnosis and symptoms necessitating the procedure
• Details of the surgical approach and technique used
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 69910, it is important to ensure that the procedure is performed by a qualified healthcare professional and is medically necessary for the patient’s condition. It is also important to follow any specific billing guidelines provided by the payer. CPT code 69910 should not be reported with other codes unless specifically instructed by the payer.

8. Historical information

CPT code 69910 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 complete hearing loss in one ear and severe vertigo undergoes a labyrinthectomy with mastoidectomy to alleviate their symptoms.
2. A provider performs a labyrinthectomy with mastoidectomy on a patient who has been experiencing debilitating dizziness and has no hearing in one ear.
3. A labyrinthectomy with mastoidectomy is performed on a patient with a history of chronic ear infections, resulting in complete hearing loss and persistent vertigo.
4. A patient with a tumor in the inner ear undergoes a labyrinthectomy with mastoidectomy to remove the diseased tissue and alleviate their symptoms.
5. A provider performs a labyrinthectomy with mastoidectomy on a patient with Meniere’s disease, a condition characterized by recurring episodes of vertigo and hearing loss.
6. A patient with a congenital malformation of the inner ear undergoes a labyrinthectomy with mastoidectomy to improve their balance and alleviate their symptoms.
7. A labyrinthectomy with mastoidectomy is performed on a patient with a history of recurrent ear infections and chronic dizziness.
8. A provider performs a labyrinthectomy with mastoidectomy on a patient with a traumatic injury to the inner ear, resulting in complete hearing loss and persistent vertigo.
9. A patient with a severe inner ear infection undergoes a labyrinthectomy with mastoidectomy to remove the infected tissue and alleviate their symptoms.
10. A labyrinthectomy with mastoidectomy is performed on a patient with a rare genetic disorder affecting the inner ear, resulting in complete hearing loss and chronic vertigo.