Otolaryngology Coding Alert

The removal of most cholesteatomas of the tympanic membrane and middle ear during tympanostomy or tympanoplasty are incidental and should not be coded separately, coding experts say. Coders should read the operative report to see what specific steps were taken during a procedure to choose the best code. Further, reimbursement opportunities increase when anesthesia is administered.

Dorlands Medical Dictionary defines cholesteatoma as a cyst-like mass or benign tumor with a lining of stratified squamous epithelium, usually of keratinizing type, filled with desquamating debris frequently including cholesterol. They are found most commonly in the middle ear and mastoid region, usually after a trauma or infection that heals poorly.

Cholesteatomas also may be found on the tympanic membrane. These usually are associated with chronic infection of the middle ear. In the following operative report, the otolaryngologist encounters and excises a cholesteatoma (referred to in the operative note as a keratoma) on the patients outer eardrum (tympanic membrane), during the course of performing a tympanostomy.

Operative Report

Preoperative diagnosis: Bilateral chronic otitis media
Postoperative diagnosis: Same
Operation/procedure performed: Bilateral myringotomy and tubes
Anesthesia: General anesthesia

Description of procedure:
The patient was placed in the supine position, prepped and draped in the usual sterile fashion, under general anesthesia by mask. The right ear was visualized under a microscope after removing obstructing cerumen with the cerumen curet. The ear was irrigated with sterile saline solution. A myringotomy blade was used to make an antero-inferior radical myringotomy incision. A scant amount of fluid was suctioned from the middle ear space with a # 5 Frazier suction. A Pope-type myringotomy tube was inserted and Cortisporin Otic drops were applied. Attention was then directed to the left ear. Visualized under a microscope, obstructing cerumen was removed with a cerumen curet. The external auditory canal was irrigated with sterile saline solution and suctioned out with a # 5 suction. The tympanic membrane was inspected. There was a small antero-inferior retraction pocket that contained some keratinous debris. This was carefully removed with alligator forceps. A small keratin plug was sent for pathology. There was an area of atelectasis where this keratin plug was, and the myringotomy was made antero-inferiorly to excise a portion of this atelectatic area. After the myringotomy incision was made, # 5 suction was used to suction the middle ear space. A scant amount of fluid was encountered. A Pope-type myringotomy tube was inserted, and Cortisporin Otic drops were applied. At this point the procedure was terminated. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

Coding the Procedure

Because the operative report documents that general anesthetia was administered to the patient, the myringotomy with insertion of tubes (referred to in as a tympanostomy) should be coded 69436 (tympanostomy [requiring insertion of ventilating tube], general anesthesia). Had local or topical anesthesia been used, the correct code would have been 69433 (tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia).

The diagnosis codes for the operative session are 381.10 (chronic serous otitis media, simple or unspecified) for the tympanostomy and 385.30 (cholesteatoma, unspecified). (Note that the cholesteatoma was omitted on the postoperative diagnosis at the top of the report.) The removal of the cholesteatoma on the tympanic membrane should not be billed separately because it is incidental to the tympanostomy, says Lee Eisenberg, MD, an otolaryngologist in Englewood, N.J., and a member of the American Medical Associations CPTs editorial panel and executive committee.

Removing the cholesteatoma usually doesnt take a lot of time and is considered part of the tympanostomy, Eisenberg says. Therefore, adding modifier -22 (unusual procedural services) to the 69436 is unlikely to result in more payment, Eisenberg says, unless the operative session was lengthened significantly by the cholesteatoma removal, which normally is not the case.

The cholesteatoma may be discovered and removed in the same operative session as a tympanostomy or a tympanoplasty (69631, tympanoplasty without mastoidectomy [including canalplasty, atticotomy and/or middle ear surgery], initial or revision, without ossicular chain reconstruction). Either way, unless the circumstances were so unusual that a significant amount of extra time was added, the removal is incidental and shouldnt be billed.

Because cholesteatomas may be located on the tympanic membrane or, more commonly, in the middle ear, the diagnosis codes may vary (for example, cholesteatoma of the middle ear is 385.32), but the removal of these benign growths remains incidental to the procedure performed.

If the cholesteatoma is in the middle ear, the otolaryngologist performs a myringotomy to explore the middle ear and remove any adhesion or debris, such as a cholesteatoma. As with the cholesteatoma on the tympanic membrane, if tubes are placed, the procedure is coded as a tympanostomy. If a graft is harvested and placed on the eardrum during the same operative session, a tympanoplasty would be billed.

The middle ear section of the CPT manual includes a code that describes the excision of an aural polyp (69540, excision aural polyp), but none for other lesions or masses such as a cholesteatoma.

According to Eisenberg, a new code for middle ear excisions has been contemplated, but differences over the work values that would be assigned to such a code have complicated its introduction.

Cholesteatomas and Mastoidectomies

If the patient has a cholesteatoma of the middle ear and mastoid (the most common cholesteatoma of the ear), a mastoidectomy also may need to be performed, says Edward Babb, MD, CPC, an otolaryngologist in Lafayette, N.J. The cholesteatoma in the mastoid can eat away at the bone, resulting in, among other things, a draining ear and hearing loss.

The following six codes describe mastoidectomies performed with tympanoplasties:

69641 tympanoplasty with mastoidectomy
including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction

69642 tympanoplasty with mastoidectomy
(including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction

69643 tympanoplasty with mastoidectomy
(including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction

69644 tympanoplasty with mastoidectomy
(including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction

69645 tympanoplasty with mastoidectomy
(including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction

69646 tympanoplasty with mastoidectomy
(including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction

There also are several other CPT codes involving various types of mastoidectomies and mastoidotomies, all rather complicated procedures that are easy to confuse. Any coder who is uncertain about choosing the correct procedure should check with his or her otolaryngologist before submitting the claim.