Otolaryngology Coding Alert

Tympanic repair by definition involves some form of graft, from paper patch to more sophisticated materials, to fill the perforation in the eardrum. Therefore, in most cases, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee, grafts performed in conjunction with a myringoplasty or tympanoplasty are not separately payable.
 
Some otolaryngologists believe that if a tympano-plasty is performed through the ear canal and a second incision must be made to harvest the fascia for the graft, the graft is payable separately. However, that is not the case, Eisenberg says.
 
Harvesting the graft is part of the surgery, he says, noting that the graft is by convention included in myringoplasty, which CPT defines in 69620 as surgery confined to drumhead and donor area. This means the donor-area incision is included in the procedure, and the same logic applies to grafts performed during tympano-plasties, Eisenberg says.
 
There are some exceptions. For instance, if the otolaryngologist performs a revision tympanoplasty on the right side and, because of prior surgery, has to go to the opposite side to obtain a graft temporalis fascia, the graft should be considered separate as long as the prior surgery and lack of temporalis fascia are documented and modifier -59 (distinct procedural service) is appended to the graft code, for example, 21235 (graft of ear cartilage).

 
In addition to the perichondrial grafts that, for the most part, are included in the tympanoplasty, the otolaryngologist may also need to perform split-thickness grafts to rebuild the canal wall during canalplasty, says Randa Blackwell, coding and reimbursement specialist with the department of otolaryngology at the University of Maryland in Baltimore. These grafts are separately payable, Blackwell says, noting that in some cases even full-thickness grafts are performed.
 
Some patients who have had a lot of surgery have canal stenosis, so a split- or full-thickness skin graft may be required to repair the canal, she says, adding that if temporalis fascia, rather than skin, is used for the graft, it is not separately payable.