2025 CPT code 69603
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Auditory System Surgery Feed
Revision mastoidectomy resulting in a radical mastoidectomy.
Modifiers may be applicable. Modifier 22 (Increased Procedural Services) might be used if the procedure was significantly more complex than usual, and modifier 50 (Bilateral Procedure) is used for procedures performed on both ears during the same operative session.
Medical necessity is established by the presence of persistent or recurrent ear disease following a prior complete or modified radical mastoidectomy.This may include chronic infection (otitis media), cholesteatoma, hearing loss, or other complications that have not responded to conservative management.
The surgeon prepares the patient and administers anesthesia. An incision is made either within the ear canal or behind the ear, and the tissues are dissected to reach the previous mastoidectomy site. The posterior and superior bony canal walls are taken down to the level of the facial nerve.The ossicles are removed, but the stapes may be spared to preserve some hearing.The eustachian tube orifice mucosa, middle ear mucosa, granulation tissue, and cholesteatoma are resected. The middle ear and mastoid cavity are exposed, and a meatoplasty (reconstruction of the ear canal) is performed if necessary. Absorbable packing is placed, the wound is sutured, and a dressing is applied.
In simple words: This surgery corrects a previous ear operation (mastoidectomy) that didn't fully heal.The surgeon removes infected tissue, a growth called a cholesteatoma, and small bones in the ear. They may also rebuild the ear canal.This helps fix chronic ear infections and hearing problems.
This procedure involves revising a previous complete or modified radical mastoidectomy by performing another radical mastoidectomy. It includes the excision of the ossicles (small bones in the middle ear), eustachian tube and middle ear mucosa, granulation tissue, and cholesteatoma (a benign tumor).The ear canal may also be reconstructed if necessary. This procedure is typically performed when a previous mastoidectomy fails to resolve chronic ear infections or hearing loss.It addresses issues like recurrent otitis media with pus accumulation and eardrum perforation.
Example 1: A patient with a history of modified radical mastoidectomy presents with persistent ear drainage and hearing loss due to recurrent cholesteatoma.A revision mastoidectomy resulting in a radical mastoidectomy (69603) is performed to remove the cholesteatoma and address the infection., A child who underwent a complete mastoidectomy several years prior now has chronic otitis media and a perforated eardrum. A revision mastoidectomy converting to a radical mastoidectomy (69603) is performed to address the ongoing infection and reconstruct the ear canal., A patient with a history of mastoidectomy experiences persistent ear discharge and discomfort. Diagnostic imaging reveals granulation tissue and persistent infection within the mastoid cavity.A revision mastoidectomy resulting in a radical mastoidectomy (69603) is performed to remove the diseased tissue and attempt to achieve a dry ear.
Documentation should include operative reports detailing the extent of the revision, the specific tissues removed (ossicles, mucosa, granulation tissue, cholesteatoma), the status of the ear canal and whether reconstruction was necessary, and the reason for the revision (e.g., persistent infection, recurrent cholesteatoma). Pre- and postoperative audiograms documenting the patient's hearing levels are also essential.Further, any complications encountered during the procedure should be thoroughly documented.The medical necessity for the revision should be established with evidence of persistent symptoms or recurrent disease despite previous surgical intervention.
- Revenue Code: P1G
- Global Days : 90
- Payment Status: Active
- Specialties:Otolaryngology
- Place of Service:Ambulatory Surgical Center, Outpatient Hospital, Inpatient Hospital