What CPT (Current Procedural Terminology) code is reported for a tympanoplasty with mastoidotomy and with ossicular chain reconstruction in the right ear?

CPT Code for Tympanoplasty with Mastoidotomy and Ossicular Chain Reconstruction

The correct CPT code for a tympanoplasty with mastoidotomy and with ossicular chain reconstruction in the right ear is 69646-RT.

Understanding the Code Selection

The selection of CPT code 69646-RT is based on the specific components of the procedure described:

1. Tympanoplasty - Surgical repair of the tympanic membrane
2. Mastoidotomy - Surgical opening into the mastoid
3. Ossicular chain reconstruction - Repair or replacement of the middle ear bones
4. Right ear - Indicated by the -RT modifier

CPT Code Breakdown

• 69646 is the specific code for "Tympanoplasty with mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis"
• -RT modifier indicates the procedure was performed on the right ear

Differentiating from Other Options

Let's examine why the other codes are not appropriate:

• 69644-RT: This code is for tympanoplasty with mastoidectomy and ossicular chain reconstruction, but specifically with staging (a two-stage procedure), which is not mentioned in the scenario.

• 69636-RT: This code is for tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair) with ossicular chain reconstruction. The key difference is that 69646 includes a more extensive mastoid procedure.

• 69632-RT: This code is for tympanoplasty without mastoidectomy, with ossicular chain reconstruction and synthetic prosthesis. Since our scenario includes a mastoidotomy, this code is not appropriate.

Clinical Context

Tympanoplasty with mastoidotomy and ossicular chain reconstruction is typically performed for:

• Chronic otitis media with tympanic membrane perforation
• Cholesteatoma extending into the mastoid
• Conductive hearing loss due to ossicular chain disruption
• Tympanic membrane retraction with ossicular erosion

The procedure aims to:

• Eradicate disease
• Restore the integrity of the tympanic membrane
• Reconstruct the ossicular chain to improve hearing
• Maintain or create an aerated middle ear space

Coding Pitfalls to Avoid

• Don't confuse mastoidotomy with the more extensive mastoidectomy
• Ensure the ossicular chain reconstruction component is included in the code
• Always append the appropriate laterality modifier (-RT for right ear)
• Don't use codes for staged procedures unless the procedure is actually planned as a two-stage approach

By selecting CPT code 69646-RT, you accurately capture all components of the described procedure in the right ear.