Otolaryngology Coding Alert

Several factors make the selection of a tympanic repair code difficult. Probably the most important is that there are many tympanic repair procedures, from the relatively simple "paper patch" repair to radical tympanoplasty and mastoidectomy with ossicular chain reconstruction.
 
Tympanic perforations can be caused by trauma, middle-ear infection, cholesteatoma or other disease. Fifteen codes in the "Repair" subsection of the 69000 series (auditory section) of the CPT manual may be used to report this continuum of tympanic repair procedures, and selecting the correct code can be overwhelming.
 
The coder may lack the knowledge of medical and CPT terminology required to understand how the codes differ from each other. The otolaryngologist may be unaware that the codes do not correspond with the tympanoplasty categories (type I through type V) that he or she is familiar with. For example, mastoidectomy, a major factor in tympanoplasty coding, figures very little in determining the clinical type of tympanoplasty performed.
 
The difficulties with the codes may be further exacerbated because some of the descriptors do not necessarily match what the otolaryngologist performs.
 
"This is a classic example of the importance of using CPT rather than clinical terminology at the top of the operative report," says Randa Blackwell, coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore. She says new, inexperienced coders are unlikely to know the clinical difference between mastoidectomy and mastoidotomy, as well as the clinical subtleties that differentiate radical from modified radical, or a tympanoplasty with mastoidectomy from a tympanoplasty/mastoidectomy with reconstructed wall.
 
However, if the otolaryngologist's documentation provides clear answers to the following questions, it may be possible to zero in quickly on the correct code.

No. 1: Was the Surgery Performed in the Office or the OR?

The simplest tympanic repair is often referred to as a paper patch and is reported with 69610 (tympanic membrane repair, with or without site preparation or perforation for closure, with or without patch). This procedure involves patching a small puncture of the eardrum with a cigarette-type paper and is typically performed in the otolaryngologist's office. Three or four applications of a patch may be needed before the perforation closes completely.
 
The paper-patch technique sometimes fails, and even if the patch is placed correctly, it does not always provide prompt or adequate closure of the tympanic membrane perforation. In such cases, the otolaryngologist may need to perform myringoplasty, which involves using a fat or soft-tissue graft (usually temporalis fascia) to repair the perforation. Unlike the paper patch, myringoplasty is typically performed in the operating room (OR) and is coded 69620 (myringoplasty [surgery confined to drumhead and donor area]).
 
Note: For a discussion on billing tympanic repair grafts, see sidebar on page 76.

No. 2: Was Surgery Confined to the Drumhead?

Myringoplasty is often confused with tympanoplasty, which is also performed in the OR. However, in CPT terms, myringoplasty (69620) is a relatively straightforward procedure (8.06 transitioned RVUs and a 10-day global period), but tympanoplasties are more complex procedures (all the tympanoplasty codes have 90-day global periods and describe procedures that require anesthesia and are performed in the OR).
 
"The key to distinguishing between myringoplasty and tympanoplasty is knowing if the surgery was confined to the drumhead, and the donor site for the graft to repair the perforation," says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPT's editorial panel and executive committee. "If the surgery was confined to the drumhead, it's a myringoplasty. This means the otolaryngologist enlarged the perforation, freshening the edges, and then placed a small piece of fat or fascia (harvested at the donor area see code descriptor) into or under the perforation. If, however, the otolaryngologist elevates the canal wall skin to repair the perforated eardrum or look at the ossicular chain inside the middle ear, the procedure is likely best described by a tympanoplasty code."
 
Myringoplasty is performed via the ear canal, but  tympanoplasty, a more complex procedure, often uses a postauricular incision, Eisenberg says.
 
Because there are a dozen tympanoplasty codes, simply noting that a tympanoplasty was performed does not provide enough information to select the correct code for the procedure. To do so, you must ask further questions:

No. 3: Was the Mastoid Affected? How Extensively?

The tympanoplasty codes in the CPT manual do not parallel the clinical classification system used by many physicians, by which tympanoplasties are placed in one of five "types," none of which include mastoidectomy. As a result, many otolaryngologists and their coders try to match, for example, a type I tympanostomy with a myringoplasty, or a type V tympanostomy with a more complicated tympanostomy code when no connection or similarity exists.
 
"The tympanoplasty-by-type terminology is not useful for coders," Blackwell says. "Although a type I tympanoplasty may sometimes conform to a 69620 myringoplasty, many procedures categorized by any of the five types may also be categorized as a basic tympanoplasty or one of its variants." Eisenberg recommends that otolaryngologists limit the use of clinical terminology to the procedure notes and use CPT terminology whenever possible at the top of the operative report.
 
To understand how CPT organizes the tympanoplasty codes, think of the codes as being arranged in four groups:
 
1. Without mastoidectomy
 
2. With mastoidectomy (or mastoidotomy)
 
3. With mastoidectomy and reconstruction of the canal wall
 
4. With modified radical or radical mastoidectomy.
 
 
Tympanoplasty may be performed with or without mastoidectomy (excision of the mastoid, a group of air cells in the bone behind the pinna). In either case, the tympanoplasty may include canalplasty (enlarging the ear canal), atticotomy (when the surgeon drills on the posterior bony canal wall to look into the attic), and/or middle-ear surgery, such as removing cholesteatomas or granulation tissue, or just looking at the ossicles.
 
If the condition that resulted in the perforated tympanic membrane is limited to the ear, the otolaryngologist performs a tympanoplasty without mastoidectomy (69631, tympanoplasty without mastoidectomy [including canalplasty, atticotomy and/or middle ear surgery], initial or revision; without ossicular chain reconstruction]). The patient is anesthetized and the middle ear is entered through either the ear canal or postauricular incision, then a piece of  temporalis fascia is placed beneath the perforation.
 
In many cases, the otolaryngologist suspects that the mastoid is affected (due to cholesteatoma or a chronic draining ear, for example) or that a mastoidectomy is needed because of a previously failed tympanoplasty. Like the ethmoid sinuses behind the nose, the mastoid, in its normal state, resembles a honeycomb composed of many bony partitions or air cells.

When a More Extensive Procedure Is Required

If the otolaryngologist decides to enter the mastoid, he or she may perform an antrotomy or mastoidotomy to view the mastoid antrum and then evaluate the need for more extensive surgery. This procedure is reported with  69635 (tympanoplasty with antrotomy or mastoidotomy [including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair]; without ossicular chain reconstruction).
 
If the otolaryngologist decides to do a more complete procedure, a mastoidectomy is performed in conjunction with the tympanoplasty. This procedure, coded as 69641 (tympanoplasty with mastoidectomy [including canalplasty, middle ear surgery, tympanic membrane repair]; without ossicular chain reconstruction), involves drilling out all or most of the cells in the mastoid.
 
If the canal wall is taken down to remove completely all the mastoid contents and is reconstructed, use 69643 ( with intact or reconstructed wall, without ossicular chain reconstruction).
 
If the patient's condition is particularly severe, a modified radical or radical mastoidectomy may be needed. Either procedure is coded 69645 ( radical or complete, without ossicular chain reconstruction). In the radical technique, the otolaryngologist removes most of the mastoid, canal wall and middle-ear bones. The modified radical mastoidectomy, meanwhile, aims to maintain an aerated middle ear.
 
Note: CPT also includes a series of codes (69501-69511) to report mastoid surgery performed without tympanoplasty.
 
According to Eisenberg, 69645 is confusing because it identifies and describes only a radical mastoidectomy. There is no code for tympanoplasty with modified radical mastoidectomy, even though this procedure is preferable and may be performed more often than the true radical mastoidectomy (neither procedure is frequently performed).
 
Eisenberg maintains that the way the codes are written implies that 69645 and its derivative, 69646, should be used for radical and modified radical mastoidectomies.

No. 4: Was Ossicular Chain Reconstruction Done?

If, during the course of any of the tympanoplasties described above, a defect in the bones is discovered in the bones of the middle ear (ossicles), or if an eroded bone had to be removed during surgery, the otolaryngologist may repair the defect by replacing the bone(s) a service referred to as ossicular chain reconstruction. Any middle- ear repairs during tympanoplasty are more likely to be attempted if the ear is dry and not infected.
 
Sometimes the need for such repairs can be determined prior to surgery. Often, however, it becomes clear to the otolaryngologist only when the ear is opened completely and examined under the operating microscope. The most common bone erosion occurs at the tip of the incus (anvil), which is connected by a piece of bone only 1.5 mm thick to the stapes (stirrup bone). If the patient had prior infections, the circulation to the bone may be obstructed, and infection can wear away the connection.
 
To repair the defect, there are several options. A piece of tragal cartilage (the cartilage in front of the ear canal) may be placed or, more commonly, the patient's incus or one from a donor is reshaped to replace the missing ossicle.
 
In some cases, a prosthesis made of synthetic material is used instead of bone. For example, the physician may insert a strut made from artificial bone. This is porous and allows blood vessels to grow, resulting in the complete assimilation of the artificial bone. 
 
Each group of tympanoplasty codes described earlier 69631, 69635 (mastoidotomy), 69641, 69643 and 69645 includes a secondary code that includes ossicular  reconstruction. Two of the categories tympanoplasty without mastoidectomy and tympanoplasty with mastoidotomy also include a tertiary code if a prosthesis is used to aid the reconstruction. The codes are listed as follows:
 

69632 tympanoplasty without mastoidectomy ..., initial or revision; with ssicular chain reconstruction (e.g., postfenestration)

69633 with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP])

69636 tympanoplasty with antrotomy or mastoid-otomy ...; with ossicular chain reconstruction
 

69637 with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP])

69642 tympanoplasty with mastoidectomy ...; with ossicular chain reconstruction

69644 with intact or reconstructed canal wall, with ossicular chain reconstruction

69646 radical or complete, with ossicular chain reconstruction.
 
If ossicular chain reconstruction is performed with either bone or a synthetic prosthesis, these codes should be used in place of the primary codes they follow.

No. 5: Was a Revision Performed?

Sometimes a tympanoplasty with mastoidectomy is performed, but the patient continues to manifest symptoms, such as cholesteatoma. Or the patient may have had acute mastoiditis that required mastoidectomy and now requires a revision mastoidectomy but also has a middle-ear disease that necessitates tympanoplasty. In such cases, the otolaryngologist may decide to perform a revision mastoidectomy, which is a much different procedure from a mastoidectomy performed on a patient with no history of previous mastoid intervention.
 
CPT includes one code (69604, revision mastoidectomy; resulting in tympanoplasty) for revision mastoidectomies performed with tympanoplasty. There is, however, no specific code for tympanoplasty revisions, Blackwell notes. If the otolaryngologist performs a revision tympanoplasty, the correct tympanoplasty code should be chosen from those listed earlier based on what
was performed.
 
If the revision makes the tympanoplasty more difficult, modifier -22 (unusual procedural services) may be used, as long as there is appropriate supporting documentation.
 
As with all documentation, the dictation that supports the request for additional fees to compensate for the extra effort required to perform the procedure should use terminology that is CPT-compatible, Blackwell says.