Otolaryngology Coding Alert

Coding these procedures correctly can be lucrative to your ENT practice. These codes pay between $631.05 and $915.20, based on the 2004 National Physician Fee Schedule.

If your otolaryngologist performs a tympanoplasty with mastoidectomy, you should choose a code from the second initial mastoidectomy section:

Medicare pays between $867.41 and $1,198.99 for these procedures, unadjusted for geographic differences.

Watch out: You could miss out on the mastoidectomy fee if you overlook the mastoid removal operation in the physician's procedure notes. "When an otolaryngologist performs a tympanoplasty to remove cholesteatoma, we often miss the mastoidectomy," says George E. Smaistrla Jr., FHFMA, clinic administrator at the three-ENT prac-tice Associated Otolaryngologists of Decatur, in Illinois.

Tip: You can avoid omitting the mastoidectomy, an error that could cost you between $236.36 and $567.94, by looking for the word "mastoid" in the tympanoplasty operative note, Smaistrla says.

Example: An otolaryngologist enters the middle ear through a canal skin flap, drills out the diseased mastoid air cells and places a piece of muscle tendon beneath
the perforation.

Action: If you highlight "mastoid" in the above operative note, you will most likely remember to use a  code for tympanoplasty with mastoidectomy (69641-69646) instead of a code for tympanoplasty (69635-69646).

2. Simple, Complete, Modified Radical or Radical

To select a mastoidectomy-only code, you should determine the mastoidectomy type:

Snag: The terms may look easy, but your otolaryngologist may not use these exact words in the operative report. You can concentrate on the initial mastoidectomy codes' differences if you know which similarities 69501-69511 share. All of these codes describe mastoidectomies, during which surgeons drill into the mastoid cortex until they open the attic and antrum, according to a presentation by Eileen Giaimo, MEd, MHA, CPC, director of economic affairs at the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS), who offered this advice at the American Academy of Professional Coders 2004 Coding Conference. You can deter-mine the exact code if you review any additional mastoid-ectomy-related work that the otolaryngologist performs.

You should report 69501 for a simple mastoidectomy. In this operation, the otolaryngologist removes disease from the mastoid air cells. But, he performs no middle-ear work, Giaimo says.

Tip: You should report a higher-level code (69502-69511) if your physician's mastoidectomy involves middle-ear work.
 
If the physician documents a complete mastoidectomy, you should report 69502. During this procedure, the otolaryngologist attempts to remove all air cells and includes an exploration of the entire "attic" or "epitympanum."

Don't miss: During a modified radical mastoid-ectomy, the otolaryngologist removes the superior and posterior canal walls to create an open mastoidectomy cavity, but he either maintains or grafts the tympanic membrane and attempts to preserve the middle-ear ossicles. You should report 69505 for this procedure.

During a radical mastoidectomy, the otolaryngologist makes no attempt to preserve the fibrous or bony annulus. And, the surgeon removes the tympanic membrane, the malleolus and the incus. You should report 69511 for a radical mastoidectomy. "Surgeons, however, rarely perform this operation, which also includes the surgeon removing the tympanic membrane," Giaimo says.

3. Confirm Surgical Combinations

If the surgeon performs a tympanoplasty in addition to a mastoidectomy, you should select the appropriate combination code from the 69641-69646 series. "Choose the code based on what the otolaryngologist performs with the tympanoplasty," says Seth M. Goldberg, MD, FACS, an otolaryngologist at Aesthetic Facial Surgery Center of Rockville in Maryland.

Try this: Double-check whether your otolaryngologist's documentation mentions a canal-wall-up or a canal-wall-down mastoidectomy with tympanoplasty. During a canal-wall-up mastoidectomy, the otolaryngologist preserves the posterior and superior bony canal walls. A canal-wall-down mastoidectomy involves drilling down the posterior and superior bony canal walls.

You should select from two code sets (69641-69642 or 69643-69644) for a canal-wall-up mastoidectomy.

Remember: If the otolaryngologist drills out all (complete) or only diseased mastoid cells (simple), you should report 69641 or 69642 when the surgeon grafts the tympanic membrane with the mastoidectomy. Think of the codes as a combination tympanoplasty and simple or complete mastoidectomy.

You should report 69643 or 69644 if the surgeon performs a tympanoplasty with an intact or reconstructed canal wall. In this procedure, the otolaryngologist may take down the posterior canal wall and reconstruct it using cartilage, bone or hydroxyapatite.

If the surgeon documents a canal-wall-down mastoidectomy, you should consider 69645 or 69646. These codes describe the surgeon's work drilling away the canal wall. Think of this code set as including a modified radical or a radical mastoidectomy.
 
4. Look for Ossicular Reconstruction

You can select the final code if you know whether the tympanoplasty with mastoidectomy procedure involves ossicular reconstruction. Each of the above tympanoplasty with mastoidectomy codes (69641-69646) has two counterparts:

Strategy: If the surgeon reconstructs the ossicular chain using the patient's ossicles, you should report the reconstructive component code, Goldberg says.

Translation: Use the even codes (69642, 69644, 69646) if the physician performs tympanoplasty with mastoidectomy using  patient-supplied ossiculoplasty to repair a defect or eroded middle-ear bone.