2025 CPT code 69601

Revision mastoidectomy resulting in complete mastoidectomy.

Refer to CPT coding guidelines for proper use and reporting of this code.

Modifiers are applicable. Common modifiers include 22 (Increased Procedural Services), 50 (Bilateral Procedure), 52 (Reduced Services), and others to specify details of the procedure.

Medical necessity must be established by documentation of persistent or recurrent ear disease despite previous surgical intervention.This may include imaging studies (CT scan), audiological testing, and physical exam findings demonstrating active infection, cholesteatoma, or significant hearing impairment.

IMPORTANT For repeat mastoidectomy resulting in a modified radical mastoidectomy, use 69602. For radical mastoidectomy following previous mastoidectomy, use 69603. For revision mastoidectomy resulting in tympanoplasty, use 69604.

In simple words: This is a surgery to fix a previous ear operation (mastoidectomy) that didn't fully resolve the problem. The surgeon reopens the area behind the ear, cleans out any remaining infection or abnormal tissue, and reconstructs the area to promote healing and prevent further issues like ear infections and hearing loss.

This procedure involves revising a previous simple mastoidectomy to a total mastoidectomy, including removal of diseased mastoid mucosa or cholesteatoma if present.It addresses persistent ear problems like recurrent otitis media with pus accumulation, eardrum perforation, and hearing loss, often due to the initial procedure not achieving a dry ear.The surgeon accesses the mastoid cavity through an incision behind the ear, drills out the cavity to expose key structures while preserving the posterior ear canal wall, removes diseased tissue and cholesteatoma, controls bleeding, and closes the incision with possible drainage and dressing.

Example 1: A patient with persistent ear discharge and hearing loss after a simple mastoidectomy undergoes revision mastoidectomy (69601) to remove residual infected tissue and achieve a dry ear., A patient with recurrent cholesteatoma formation following a prior mastoidectomy requires a revision procedure (69601) to remove the cholesteatoma and prevent further complications., A patient with a perforated eardrum and chronic otitis media, despite previous mastoid surgery, undergoes a revision mastoidectomy (69601) to address the ongoing infection and potentially improve hearing.

Documentation should include operative report detailing the extent of the revision, findings of infection or cholesteatoma, procedures performed, and any complications. Pre- and post-operative audiograms may be necessary to assess hearing changes.

  • Revenue Code: P1G - Major Procedure - Other
  • Specialties:Otology, Neurotology
  • Place of Service:Ambulatory Surgical Center, Hospital - Inpatient, Hospital - Outpatient
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