Otolaryngology Coding Alert

If graft coding in complex myringoplasty or tympanoplasty cases always leaves you with more questions than answers, your solution just got easier.

You don't have to look at whether the graft and surgery occurred on different sides. Just check whether the surgeon had to make two incisions.

If the otolaryngologist has to obtain the graft material from a separate incision, you should code the harvest, according to the American Academy of Otolaryngology -- Head and Neck Surgery (AAO-HNS).

For graft harvest coding, sites, not sides, matter. Apply this expanded codeability to both myringoplasty and tympanoplasty (69631, Tympanoplasty without mastoidectomy [including canalplasty, atticotomy and/or middle ear surgery], initial or revision; without ossicular chain reconstruction).

Problem: The answer to -You Be the Coder: Is Graft Inherent in Myringoplasty?- (Otolaryngology Coding Alert, Vol. 9, No. 8) suggests that you should separately code for graft harvesting (such as 20926, Tissue grafts, other [e.g., paratenon, fat, dermis]) only when the surgeon obtains the graft from the contralateral side -- the side where the myringoplasty (69620, Myringoplasty [surgery confined to drumhead and donor area]) did not occur.

-If the otolaryngologist harvests a graft from the right ear for placement on the right ear during a myringoplasty, include the graft in 69620 (Myringoplasty [surgery confined to drumhead and donor area]),- the YBC says.

The answer -sparked a number of discussions among AAO-HNS physician leaders,- says Debi Henley Lansey, MPA, senior manager of socioeconomic affairs at the AAO-HNS. -We respectfully disagree with the coding advice,- she tells Otolaryngology Coding Alert.

The Academy's rationale makes sense. You usually include same-site incisions in the more complex procedure. But coding convention typically allows coding for procedures involving separate incisions, regardless of side.

The Academy submitted an article on coding grafts with ear surgery to the AMA's CPT Assistant. Use the following entry, which has the consensus of the AAO-HNS 3P Group, to appeal any denials for graft harvesting involving a separate incision from myringoplasty or tympanoplasty.

-From a CPT coding perspective, code 69631, Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction, includes harvesting the tympanic membrane grafting material if'performed through the same incision (e.g., endaural or postauricular approach).'However, if cartilage, fascia or other tissue obtained through a separate incision is used to reconstruct the tympanic membrane, canal wall, attic, etc., the harvesting of that graft may be separately reported (e.g., 20926, 21235)- Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft).

Lesson learned: Bill for graft harvesting that involves a separate incision from myringoplasty or tympanoplasty, per AAO-HNS and AMA advice.