Otolaryngology Coding Alert

Question: I understood that 69450 (tympanolysis) is for time spent cleaning out a patient's badly infected ear, including removing granulation tissue and adhesions from the surface of the eardrum. After the cleaning, the physician usually applies silver nitrate cautery to the bleeding base. When I do not make  a postauricular incision and actually raise the tympanomeatal flap to get into the middle ear, can I still use this code, possibly with modifier 52?

Ohio Subscriber

Answer: No. Because 69450 (Tympanolysis, transcanal) is a middle-ear procedure, you should not bill it with modifier 52 (Reduced services) if you did not enter the middle ear. Reserve modifier 52 for cases in which you partially reduce or eliminate a service or procedure but you still perform the basic service. This may involve a bilateral procedure that you did on only one side for various reasons.

For instance, Medicare and most other carriers consider tonsillectomy a bilateral procedure, which means the insurer calculates the procedure's value based on the assumption that the physician treats both sides of the throat. If an otolaryngologist excises or destroys only one tonsil, you should append modifier 52 to the appropriate tonsillectomy code, such as 42825 (Tonsillectomy, primary or secondary; younger than age 12). In unilateral tonsillectomy, the otolaryngologist still performs the base procedure, making the use of modifier 52 on the tonsillectomy code appropriate.

In contrast, tympanolysis is in CPT's middle-ear section, making this anatomical location a code requirement. The Coders' Desk Reference notes that in 69450 the otolaryngologist "treats a lesion or other irritation to the tympanic membrane." Using an operating microscope, the physician removes adhesions (or scar tissue, in this case) from the eardrum's surface.

Do not separately report use of the operating microscope (69990, Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) in addition to 69450. The Correct Coding Initiative (CCI) bundles 69990 into 69450 and does not allow a modifier to bypass the edit.

Solution: No CPT code specifically describes cleaning out the external ear. You should use the unlisted-procedure code for the external ear (69399). Submit documentation with the claim for the unlisted- procedure code explaining the work you did.

You can compare the procedure to 69450 while pointing out the codes' anatomical difference.