2025 CPT code 69631
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Auditory System Surgery Feed
Tympanoplasty without mastoidectomy, including canalplasty, atticotomy, and/or middle ear surgery; without ossicular chain reconstruction.
Modifiers may be applicable depending on the circumstances of the procedure.Consult the CPT manual and payer guidelines for appropriate modifier use (e.g., 50 for bilateral procedures, 59 for distinct procedural services).Modifiers 22, 51, 52, 78, and 79 are examples of other relevant modifiers to consider for proper reimbursement.
Medical necessity for tympanoplasty is established by the presence of a symptomatic tympanic membrane perforation, recurrent or persistent ear infections, conductive hearing loss, or other indications affecting the middle ear.Documentation should support the diagnosis and justify the surgical intervention.
The otolaryngologist or surgeon is responsible for performing the procedure. This includes patient preparation, anesthesia administration (if applicable), surgical technique,harvesting of graft material, and post-operative care.
In simple words: This surgery repairs a hole in the eardrum.It might also involve fixing the ear canal and/or making a small cut in a part of the middle ear.It does not involve removing bone behind the ear or fixing the tiny bones in the middle ear.
This code represents a tympanoplasty procedure where the tympanic membrane (eardrum) is reconstructed to repair a perforation.The procedure may include canalplasty (ear canal reconstruction), atticotomy (incision into the tympanic attic), and/or other middle ear surgeries.However, it specifically excludes mastoidectomy (removal of the mastoid) and ossicular chain reconstruction. The procedure involves prepping and anesthetizing the patient, incising the ear canal (postauricular or transcanal approach),rimming the perforation (roughening the edges of the tympanic membrane), reflecting the eardrum forward, removing adhesions, skin debris, or cholesteatoma. The ossicles are inspected but not reconstructed.A fascial graft or other tissue is harvested to repair the eardrum tear.Packing may be placed in the middle ear to support the graft.The skin in the ear canal is repositioned and packed. External incisions are sutured and dressed.
Example 1: A patient presents with a persistent perforation of the tympanic membrane due to a previous ear infection.The surgeon performs a tympanoplasty using a temporalis fascia graft, repairing the perforation without the need for mastoidectomy or ossicular chain reconstruction., A patient with chronic otitis media and a perforated eardrum undergoes a tympanoplasty. The surgeon addresses the perforation and also reconstructs a portion of the ear canal (canaloplasty) to improve ventilation and drainage., A patient with a history of trauma to the ear presents with a tympanic membrane perforation. The surgeon performs a tympanoplasty with atticotomy to access and address a small cholesteatoma in the middle ear attic. The procedure is completed without ossicular chain repair or mastoidectomy.
Preoperative evaluation including otoscopic examination, audiometry, and imaging (if indicated).Intraoperative findings detailing the extent of the perforation, presence of cholesteatoma or other pathology.Type of graft used, and technique of tympanoplasty.Postoperative instructions, follow-up plan, and any complications.
** Accurate coding requires thorough documentation of the procedure, including the approach used (transcanal or postauricular), the type and source of the graft material, and any additional procedures performed.Always refer to the most recent CPT manual and payer-specific guidelines for the most accurate coding and reimbursement.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: Refer to the current Medicare Physician Fee Schedule for RVU values and reimbursement rates.These values vary based on geographic location and other factors.
- Global Days : The global period for this procedure is not explicitly defined in the CPT code description and requires clarification based on payer-specific guidelines.Consult your local Medicare Administrative Contractor (MAC) for more information.
- Payment Status: Active
- Modifier TC rule: The Technical Component (TC) modifier may apply to this code.The application depends on whether the surgeon performs the procedure in their own facility or if a separate technical component is provided by anesthesiologists, surgical assistants, or others.
- Fee Schedule : Historical fee schedule information is not available in the provided data; you may wish to consult third-party resources.
- Specialties:Otolaryngology, Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office