Otolaryngology Coding Alert

Question: An otolaryngologist performs a tympanoplasty with mastoidectomy and makes a separate incision for a tragus cartilage graft. Should I use 21235 for the graft?


North Carolina Subscriber

Answer: The graft is not separately payable unless it occurs on the other side from the tympanoplasty with mastoidectomy. Tympanic repair by definition involves some form of graft. Therefore, grafts performed in conjunction with a myringoplasty or tympanoplasty are usually not separately payable.

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. 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 tympanoplasties.

Exceptions: If the otolaryngologist performs a tympanoplasty with mastoidectomy on the right side and, because of prior surgery, has to go to the opposite side to obtain a cartilage graft, you should consider the graft separate. Documentation must show the prior surgery and lack of cartilage. In these cases, append modifier 59 (Distinct procedural service) to the graft code (21235, Graft; ear cartilage, autogenous, to nose or ear [includes obtaining graft]). Split- and full-thickness grafts using skin are also separately payable.

For a same-side 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.