2025 CPT code 69604

Revision mastoidectomy resulting in tympanoplasty.

Use this code for revision mastoidectomy resulting in tympanoplasty.Do not use this code for planned secondary tympanoplasty after mastoidectomy (see 69631, 69632) or for skin grafts (see 15120, 15121, 15260, 15261).

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 previous mastoidectomy to resolve the underlying ear pathology, leading to ongoing symptoms such as recurrent infections, persistent drainage, eardrum perforation, and hearing loss that impact the patient's quality of life.

The surgeon performs the revision mastoidectomy and tympanoplasty, including prepping and anesthetizing the patient, making the incision, dissecting tissues, reconstructing the tympanic membrane, controlling bleeding, suturing the incision, and applying a dressing.

IMPORTANT For planned secondary tympanoplasty after mastoidectomy, see 69631, 69632. For skin graft, see 15120, 15121, 15260, 15261. For repeat mastoidectomy resulting in a complete mastoidectomy, report 69601. For repeat mastoidectomy resulting in a modified radical mastoidectomy, report 69602. For radical mastoidectomy following previous mastoidectomy, report 69603.

In simple words: This procedure is a revision of a previous ear surgery (mastoidectomy) that also includes reconstruction of the eardrum (tympanoplasty). It is done when the initial surgery did not resolve ear problems, such as infections, drainage, and hearing loss.The surgeon makes an incision in or behind the ear to access the area of the prior surgery.They reconstruct the eardrum using a graft and may pack the ear to control bleeding.This helps to create a dry ear and improve hearing.

The provider revises a previously performed mastoidectomy in conjunction with a tympanoplasty (reconstruction of the eardrum). This revision is necessary due to the failure of the prior procedure to produce a dry ear, resulting in recurrent otitis media with pus accumulation, eardrum perforation, and recurrent or residual hearing loss.The procedure involves making an incision within the ear canal or behind the ear and dissecting tissues down to the previous mastoidectomy site. The posterior and superior bony canal walls are taken down to the level of the facial nerve.The tympanic membrane is reconstructed by roughening the edges of the perforation and placing a fascia graft under or over the eardrum remnant.Ossicle reconstruction is not performed. Absorbable packing may be placed in the middle ear, and the ear canal and mastoid cavity are packed to control bleeding. The incision is sutured closed, and a dressing is applied.

Example 1: A patient with recurrent ear infections and hearing loss after a previous mastoidectomy undergoes revision mastoidectomy with tympanoplasty using a fascia graft., A child with chronic otitis media and perforation of the eardrum, despite a prior mastoidectomy, undergoes a revision procedure including tympanoplasty to reconstruct the eardrum., An adult with persistent drainage from the ear and residual hearing loss following a mastoidectomy requires revision surgery with tympanoplasty to address the ongoing issues.

Documentation should include the history of the previous mastoidectomy, the reason for revision (e.g., recurrent infections, persistent drainage, hearing loss), operative details of the revision procedure, type of graft used for tympanoplasty, and post-operative status.

  • Revenue Code: P1G
  • Specialties:Otolaryngology
  • Place of Service:Ambulatory Surgical Center, Hospital Inpatient, Hospital Outpatient, Office
** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.