Otolaryngology Coding Alert

Question: I have a question regarding harvesting of graft(s) during tympanomastoidectomy. This surgeon states he harvested a large temporalis graft as well as a tragal cartilage graft. The tragal cartilage graft was placed lateral to the chordatympani on the surface of the malleus. The temporalis fascia graft was placed in an underlay fashion underneath the tympanomeatal flap. I know the graft is included if obtained from the same site. Would both of these grafts be included in the procedure code 69641? 

Texas Subscriber

Answer: By definition, tympanic repair involves some form of graft. Therefore, grafts performed in conjunction with a myringoplasty or tympanoplasty are usually not separately payable unless the graft occurs on the other side from the typanoplayst. Some otolaryngologists believe that if a tympanoplasty is performed through the ear canal and a second incision must be made to harvest the cartilage for the graft, the graft is payable separately. However, that is not the case.

Harvesting the graft is part of the surgery if it is performed via the same incision. The graft is by convention included in myringoplasty, which CPT® defines in 69620 (Myringoplasty [surgery confined to drumhead and donor area]) as surgery confined to the drumhead and donor area. This means the donor-area incision is included in the procedure, and the same logic applies to grafts performed during tympanoplasties.

Exceptions: If the otolaryngologist performs a tympanoplasty with mastoidectomy and has to make a separate incision to obtain a cartilage graft, you should consider the graft, 21235 (Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)) separate. Documentation must demonstrate the separate incision. 

For tympanoplasty with mastoidectomy, choose the appropriate code from 69641-69646, such as 69641 (Tympanoplasty with mastoidectomy [including canalplasty, middle ear surgery, tympanic membrane repair]; without ossicular chain reconstruction). Include the graft incision in the tympanoplasty with mastoidectomy if a separate incision is not documented.