Otolaryngology Coding Alert

Question: A surgeon performs meatoplasty on the right ear, and tympanoplasty on the left ear. Can I report the procedures separately? How should I code it?

Idaho Subscriber

Answer: Yes, you can report the meatoplasty and tympanoplasty procedures separately because they occurred in different anatomical areas, the right and the left ear respectively. You would report 69646 (Tympanoplasty with mastoidectomy [including canalplasty, middle ear surgery, tympanic membranerepair]; radical or complete, with ossicular chain reconstruction) with modifier LT (Left side). You would report 69310 (Reconstruction of external auditory canal [meatoplasty] [e.g., for stenosis due to injury, infection] [separate procedure]) with modifiers 59 (Distinct procedural service) and RT (Right side).

Why modifier 59: With this modifier, you would indicate that the procedures are separate, with the location modifiers providing further proof of this by indicating that the meatoplasty and tympanoplasty occurred on separate (contralateral) sides.

In cases where the surgeon performs meatoplasty and tympanoplasty on the same side of the ear, you should not bill the 69310, 69646 combination. CPT® designates 69310 as "separate procedure," which means you can bill this procedure only if it is the only procedure the physician provides in a given anatomical area. CPT® automatically includes 69310 in any more extensive procedure provided in the same area during the same operative session.