CPT Code for Revision Mastoidectomy with Cholesteatoma Removal and Ossicular Reconstruction
The appropriate CPT code for this procedure is 69641 (Tympanoplasty with mastoidectomy, including canalplasty, middle ear surgery, tympanic membrane repair; with ossicular chain reconstruction and synthetic prosthesis).
Rationale for Code Selection
This surgical case involves three distinct but integrated components that must be coded together:
Revision cortical mastoidectomy with facial recess approach - The surgeon performed a complete mastoidectomy to remove cholesteatoma from both the mastoid cavity and middle ear, identifying critical anatomical landmarks including the sigmoid sinus, middle fossa plate, lateral semicircular canal, and facial nerve 1, 2
Cholesteatoma removal - Extensive debridement of cholesteatoma matrix from the mastoid cavity, antrum, and middle ear space was performed, which is integral to the mastoidectomy procedure 3
Ossicular reconstruction with TORP and cartilage grafting - A Total Ossicular Replacement Prosthesis (TORP) measuring 4.5 mm was placed from the oval window, with conchal cartilage positioned to support the reconstruction 4
Key Coding Considerations
CPT 69641 encompasses all three components because it specifically describes tympanoplasty with mastoidectomy that includes ossicular chain reconstruction using a synthetic prosthesis (the TORP) 1, 2. The code inherently includes:
- The mastoidectomy procedure (whether primary or revision)
- Middle ear surgery and tympanic membrane/canal wall repair
- Ossicular chain reconstruction with prosthetic material
- Associated cartilage grafting for structural support 4
The conchal cartilage harvest is separately reportable using CPT 20910 (Cartilage graft; costochondral) or 20912 (Cartilage graft; nasal septum), though 21235 (Graft; ear cartilage, autogenous, to nose or ear) may be more anatomically specific for conchal cartilage harvest 1
Important Coding Pitfalls to Avoid
Do not separately code the facial recess approach - This is considered an integral part of the mastoidectomy and is not separately billable 2, 5
Do not use CPT 69636 (Tympanoplasty with mastoidectomy without ossicular chain reconstruction) - This patient received a TORP, which requires the code that includes ossicular reconstruction 1
Do not separately bill for cholesteatoma removal - Removal of disease is inherent to the mastoidectomy procedure and is not separately coded 2, 3
Revision status does not change the primary code - Whether this is a primary or revision mastoidectomy, the same CPT code applies based on the work performed 2
Documentation Requirements for Accurate Coding
The operative report must clearly document:
- Identification of anatomical landmarks (sigmoid sinus, middle fossa plate, facial nerve, lateral semicircular canal) to support the complexity of the procedure 5
- Complete removal of cholesteatoma from all involved areas 3
- Type and size of prosthesis used (TORP, 4.5 mm length) 4
- Cartilage graft placement and source (conchal cartilage) 4
- Facial nerve preservation techniques 5