2025 CPT code 69602

Revision mastoidectomy; resulting in modified radical mastoidectomy

Modifiers may be applicable to this code to indicate specific circumstances, such as increased procedural services (22), bilateral procedures (50), or other factors impacting the service provided.

Medical necessity for this procedure is established by the failure of a previous mastoidectomy to resolve the ear problem, leading to persistent or recurrent infections, hearing loss, or cholesteatoma formation.

The surgeon makes an incision behind the ear, accesses the mastoid cavity, removes infected tissue and bony partitions, creates a tympanomeatal flap, and may remove ossicles depending on the cholesteatoma's location. The flap is repositioned, the ear canal is reconstructed if needed, and the incision is closed.

In simple words: A surgeon revises a prior ear surgery (mastoidectomy) to a more extensive procedure (modified radical mastoidectomy) to address recurring infections and hearing problems. This involves cleaning out infected tissue, reconstructing the ear canal, and removing parts of the mastoid bone behind the ear.

This procedure involves revising a previous simple or complete mastoidectomy to a modified radical mastoidectomy. It includes removing all mastoid air cells, granulation and infected tissue, and the bony partitions of the mastoid cavity. The ear canal is reconstructed if necessary. This is performed when the initial mastoidectomy fails to resolve the ear issue, resulting in recurrent otitis media with pus accumulation, eardrum perforation, and hearing loss.

Example 1: A patient with recurrent otitis media, persistent drainage, and hearing loss after a simple mastoidectomy undergoes a revision resulting in a modified radical mastoidectomy., A patient with cholesteatoma inadequately addressed by a previous complete mastoidectomy requires a revision to a modified radical mastoidectomy., A patient with a perforated eardrum and persistent infection despite a prior mastoidectomy undergoes a revision procedure resulting in a modified radical mastoidectomy to eradicate the infection and reconstruct the ear canal.

Documentation should include the history of previous mastoidectomy, the indication for revision surgery (e.g., recurrent infection, cholesteatoma), operative findings, extent of the modified radical mastoidectomy performed, and any reconstruction of the ear canal.

  • Specialties:Otolaryngology
  • Place of Service:Ambulatory Surgical Center, Hospital, Outpatient Hospital
** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.