What is the CPT (Current Procedural Terminology) code for a left lateral graft tympanoplasty procedure?

CPT Code Selection for Left Lateral Graft Tympanoplasty

The correct CPT code for a left lateral graft tympanoplasty in this case is 69641-LT.

Rationale for Code Selection

The key factors in determining the correct code for this procedure are:

1. Type of procedure performed: Lateral graft tympanoplasty
2. Presence of tympanosclerosis: The patient has extensive tympanosclerosis
3. Surgical approach: The surgeon used an operating microscope

Code Analysis

• 69641-LT is the correct code because it represents a tympanoplasty with mastoidectomy (with or without preservation of wall) without ossicular chain reconstruction. The lateral graft technique with tympanosclerosis requires this more extensive code.

• 69631-LT would be incorrect as it represents a tympanoplasty without mastoidectomy or ossicular chain reconstruction, typically used for simpler cases.

• 69632-LT would be incorrect as it represents a tympanoplasty with ossicular chain reconstruction, which was not performed in this case.

• 69642-LT would be incorrect as it represents a tympanoplasty with mastoidectomy and ossicular chain reconstruction, which exceeds what was performed.

Understanding Tympanoplasty Techniques

Lateral graft tympanoplasty is specifically used for cases with:

• Extensive tympanosclerosis (as in this patient)
• Total or near-total perforations
• Extensive myringitis
• Anterior perforations that are difficult to repair with medial graft techniques

Research shows that lateral graft techniques have high success rates for these challenging cases:

• Initial perforation closure rates of 88.2% 1
• Final closure rates of 97.1% after revision 1
• Significant improvement in hearing outcomes 1, 2

Coding Considerations for Tympanoplasty

When coding tympanoplasty procedures, several factors must be considered:

1. Surgical complexity: The presence of tympanosclerosis increases the complexity level of the procedure 3

2. Surgical technique: Lateral graft techniques are more complex than medial graft techniques and require different coding 2, 4

3. Laterality modifier: The "-LT" modifier correctly identifies this as a left-sided procedure

4. Surgical approach: The use of an operating microscope is included in the code and does not require separate coding

Clinical Outcomes

The selected procedure (lateral graft tympanoplasty) is appropriate for this patient's condition, as research shows:

• Lateral graft techniques are superior to traditional medial techniques for large anterior or subtotal perforations 2
• Success rates of 97% have been reported for medio-lateral graft techniques 4
• Cartilage grafts (as used in this case) provide excellent outcomes for tympanic membrane reconstruction 1, 5

By selecting CPT code 69641-LT, the surgeon is accurately representing the complexity and extent of the procedure performed for this patient with extensive tympanosclerosis and a nonhealing perforation.