# 69641 vs 69643



## jmddwilson (May 14, 2019)

Can someone explain the difference in 69641 and 69643?  I have included part of the op note for details.  It seems they are similar but 69643 includes "intact or reconstructed wall", so what is included in 69641?

OPERATIVE PROCEDURE:
Canal wall up right tympanomastoidectomy.

The patient was placed under general endotracheal anesthesia and positioned in the usual fashion.  Electrodes were placed for facial nerve monitoring and the postauricular sulcus was injected with 1% xylocaine with 1:100,000 epinephrine.  She was prepped and draped in the usual fashion for a right tympanomastoidectomy procedure.  The patient was positioned under the operating microscope.  The canal wall incisions were made for the vascular strip and the tympanomeatal flap.  The vascular strip was elevated in a retrograde fashion up the posterior canal wall.  A postauricular incision and the anterior ear flap were elevated.  A fascial graft was harvested from the deep layer of the right temporalis fascia.  This was set on a Teflon block under a gooseneck lamp to dry.  The periosteum was incised and cleared off the mastoid eminence with a Lempert elevator.  Dissection proceeded down the posterior canal wall where the previously made incisions were encountered.  The vascular strip and external ear were reflected forward with a Penrose drain and Weitlaner retractor.  This allowed good visualization of the drum head.  A mastoidectomy was performed widely opening all of the mastoid air cells down into the mastoid tip.  The mastoid antrum was opened extensively.  The sigmoid sinus was identified in the posterior aspect of the mastoidectomy, but this was not exposed. 

The tympanomeatal flap was elevated and the middle ear space was entered.  The chorda tympani nerve was encountered and preserved.  Dissection proceeded more superiorly around the annulus and the stapes superstructure was identified.  It was found that the incudostapedial complex was intact.  Movement of the malleus produced good movement of the incudostapedial complex.  It was felt that an ossiculoplasty was not necessary.  The middle ear space was packed with Gelfoam impregnated with Ocuflox drops.  The edges of the perforation were freshened with a Rosen needle.  The temporalis fascia graft was then placed in underlay fashion below the inferior drum and below the perforation.  Care was taken to adjust the graft such that all edges of the perforation were underlaid with graft.  Gel-Foam pieces impregnated with Ocuflox drops were then placed below the graft to buttress its position against the drum.  The Gel-Foam was packed such that the graft was slightly bulging out of the perforation.  The tympanomeatal flap was replaced in anatomical position.  Further compressed Gelfoam impregnated with mupirocin ointment placed overlying the reconstructed drum.  The vascular strip and external ear were replaced to their normal position.  The periosteum was closed using 4-0 Vicryl. 4-0 Vicryl was used to close the subdermal layer, 5-0 nylon interrupted simple sutures was used to close skin.  Mupirocin ointment was placed in the external auditory canal.  A Glasscock dressing was applied to the external ear.  The patient tolerated the procedure well and was taken to the recovery room in good condition.

Thank you in advance.


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## meghanhannus (May 14, 2019)

Hello jmddwilson,

Here is a description of each procedure you mention; I underlined the differences:

*CPT 69641-*The physician makes incisions in the ear canal to develop a posterior tympanomeatal flap that is reflected forward. Through a postaural or endaural incision, the physician drills out the mastoid cortex. The mastoid antrum is identified. Granulations and any cholesteatoma are removed. The posterior bony canal wall is taken down to the level of the facial nerve. The middle ear is explored, and lysis of any adhesions is performed. Any squamous debris or middle ear cholesteatoma is removed and the physician inspects and palpates the ossicles. No ossicular reconstruction is done at this time. Some fascia from the temporalis muscle or other tissues is harvested as a graft to repair the tympanic membrane perforation. Some packing may be placed in the middle ear to support the graft. The graft may be placed under (underlay or medial graft technique) or on top of the remaining eardrum (overlay or lateral graft technique). The posterior skin flap and reconstructed eardrum are repositioned to cover the facial ridge and part of the mastoid cavity. A meatoplasty is performed. The mastoid cavity and ear canal are packed, the incision sutured, and a dressing placed.

*CPT 69643-*Through a postauricular incision, the physician removes the mastoid cortex (outer bone) and drills out the mastoid air cells. The edges of the tympanic membrane are roughened ("rimming the perforation"). The physician reflects the eardrum forward. The middle ear is explored, and lysis of any adhesions is performed. Any squamous debris or middle ear cholesteatoma is removed and the physician inspects and palpates the ossicles. No ossicular reconstruction is done at this time. If the posterior canal wall is taken down, it is reconstructed with cartilage, bone, or hydroxyapatite (i.e., Wehr's canal wall reconstruction). Some fascia from the temporalis muscle or other tissues is harvested as a graft to repair the tympanic membrane perforation. Some packing may be placed in the middle ear to support the graft. The graft may be placed under (underlay or medial graft technique) or on top of the remaining eardrum (overlay or lateral graft technique). The canal skin is repositioned and the canal and mastoid cavity are packed. Any external incisions are sutured, and a dressing is applied.


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## jmddwilson (May 14, 2019)

Thank you


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