Otolaryngology Coding Alert

Question: My otolaryngologist performs middle-ear exploration with stapes mobilization. Should I report 69440 for the exploration or does a code exist for the stapes mobilization?
 
California Subscriber

Answer: CPT assigns 69650 (Stapes mobilization) for stapes mobilization. When your otolaryngologist performs middle-ear exploration (69440, Middle-ear exploration through postauricular or ear canal incision) that results in a procedure, you should charge for the operation, not the middle-ear exploration. That's because middle-ear exploration is a separate procedure in which the otolaryngologist performs no major treatment. When the surgeon performs a surgical procedure, such as stapes mobilization (69650), the middle-ear exploration (69440) becomes a component of the primary service (69650). Therefore, in your example, you should report only 69650 for the stapes mobilization.