Otolaryngology Coding Alert

Start by digging into descriptors to better understand the service.

Myringoplasty, tympanoplasty, and tympanostomy tube removal are three of the most common ear procedures an otolaryngologist typically performs. But are you sure you’re coding them correctly? Read on for our top advice on acing these claims.

Think ‘Patch’ for Myringoplasty

Your physician performs myringoplasty to repair a perforation in the tympanic membrane or the eardrum. The perforation can be created, for example, to put a tube in the ear, or it can be traumatic. The coding is dependent on what is used to repair the perforation and the extensiveness of the repair.  The simplest of repairs is called a “paper patch graft” because of what the surgeon uses to make the repair.

You have two CPT^® codes for the repair, depending on exactly what the surgeon does:

• 69610 – Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch
• 69620 – Myringoplasty (surgery confined to drumhead and donor area).

The difference: Code 69610 represents a less extensive procedure when the repair is made with a patch. When the surgeon refers to a “paper patch graft,” he is referring to 69610. The work of 69620 is more involved and might include harvesting a separate graft to repair the eardrum. It includes repairing the tympanic membrane rather than patching it.

“The grafting material used includes a piece of fascia or a plug of fat,” explains Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC. Because the description indicates “surgery confined to drumhead and donor area,” the myringoplasty includes the graft. It is not recommended that you do not bill for 20926 (Tissue grafts, other [e.g., paratenon, fat, dermis]) in addition to 69620, regardless of separate incisions or different sites (meaning not the myringoplasty ear).

Both 69610 and 69620 represent unilateral procedures. If the otolaryngologist performs either procedure bilaterally, be sure to append modifier 50 (Bilateral procedure) on the claim.

Watch for Bone Repair With Tympanoplasty

During tympanoplasty, the surgeon repairs a hole in the patient’s eardrum or lifts the eardrum to repair the small bones of the middle ear. The three CPT^® codes for tympanoplasty are distinguished by whether the physician only repairs the eardrum or also completes other repairs:

• 69631 – Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction
• 69632 – Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular 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]).

The term “mastoidectomy” means the surgeon removes the mastoid. None of these codes for tympanoplasty include mastoidectomy, so the distinctions lie in what is done to the ossicular chain (the three bones – mallus, incus, and stapes – that are necessary for hearing).

The difference: During 69631, the physician only repairs the hole in the eardrum. Code 69632 represents eardrum repair plus ossicular chain reconstruction using the bones themselves. The most extensive procedure is 69633, when the surgeon repairs the eardrum and reconstructs the ossicular chain by using some type of synthetic prosthesis to replace one of the bones that isn’t working correctly.

As with myringoplasty, the tympanoplasty codes are unilateral. Include modifier 50 for bilateral procedures.

Ignore the approach: Your otolaryngologist might choose to complete tympanoplasty by using either a transcanal approach (through the ear canal) or a post-auricular approach (by making an incision behind the ear). The approach will not affect your code choice; only the procedure itself will dictate how you file.

“Unlike 69620, codes 69631-69633 do not refer to the donor area for a graft if used,” Cobuzzi says. “A graft is separately reportable when the otolaryngologist obtains cartilage, fascia or other tissue through a separate incision. It is paramount that the separate incision (usually from the opposite side) be documented in the operative note in order to bill the graft with these codes. However, the separate incision need not be on the opposite side in order to be codeable. It just needs to be clear in the documentation that the graft was harvested from a separate incision.”

Verify Anesthesia Before Coding Tympanostomy Tube Removal

Ventilation tube removals are so common and usually so uncomplicated that the service often is done in-office with local anesthesia. Under those circumstances, the removal is included in the applicable E/M office visit code instead of coded separately.

If the tube removal requires general anesthesia, however, you report it with 69424 (Ventilating tube removal requiring general anesthesia) instead of an E/M code. Your physician will perform this procedure in the OR, not the office.

No FBR allowed: One important thing to remember about tympanostomy tube removal is that the tube is not considered a foreign body. It is not referred to as a foreign body when they physician inserts it, so 69424 doesn’t count as foreign body removal.

Also note: Tube removal does not have to be performed by the same physician who originally inserted them. Any physician who removes the tubes under general anesthesia can report 69424 for the service.

Once again, the work of 69424 is a unilateral procedure. Append modifier 50 for bilateral tube removals.