2025 CPT code 69636
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Auditory System Surgery Feed
Tympanoplasty with antrotomy or mastoidotomy, including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair; with ossicular chain reconstruction.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 52 for reduced services, 59 for distinct procedural service).Refer to the CPT manual for appropriate modifier usage.
Medical necessity is established by the presence of a perforated tympanic membrane impacting hearing and/or the presence of middle ear pathology requiring surgical intervention. Documentation should support the need for the ossicular chain reconstruction.
The otolaryngologist is responsible for the pre-operative evaluation, surgical procedure, and post-operative care. This includes the incision, mastoid removal, eardrum repair, ossicular chain reconstruction, and wound closure.
In simple words: This ear surgery repairs a hole in the eardrum and the tiny bones in the middle ear to improve hearing.It also involves removing some bone behind the ear. The surgeon will make an incision behind the ear to access and repair the damaged structures.A graft might be used to repair the eardrum.
This procedure involves the reconstruction of the tympanic membrane (eardrum) to repair a perforation and the reconstruction of the ossicular chain to improve conductive hearing.It also includes the removal of all or a portion of the mastoid.The procedure may involve ear canal reconstruction, an incision into the tympanic attic, tympanic membrane repair, and other middle ear surgeries.The surgeon makes a postauricular incision to access the mastoid, removes the mastoid cortex and air cells, enters the mastoid antrum, and prepares the edges of the tympanic membrane. Adhesions, skin debris, or cholesteatoma are removed from the middle ear. The ossicles are inspected and repositioned, possibly with replacement using a donor ossicle, bone strut, or cartilage.A fascial graft or other tissue is used to repair the eardrum perforation. Packing may be placed in the middle ear to support the graft. The ear canal skin is repositioned and packed, and exterior incisions are sutured.
Example 1: A patient presents with chronic otitis media with a perforation of the tympanic membrane and ossicular chain disruption.69636 is used to repair the eardrum and reconstruct the ossicular chain., A patient with a history of cholesteatoma undergoes a mastoidectomy and tympanoplasty.69636 is used if ossicular chain reconstruction is necessary., A patient with a previous tympanoplasty requiring revision due to recurrent perforation and hearing loss undergoes the procedure again. Code 69636 is used if ossicular chain reconstruction is performed during the revision.
* Preoperative evaluation including audiometry and imaging (CT scan).* Operative report detailing the procedure performed, including specific details of the ossicular chain reconstruction.* Postoperative audiogram.* Pathology report if applicable (e.g., cholesteatoma).
** Accurate coding requires careful review of the operative report to ensure that all components of the procedure are properly documented.In cases of uncertainty, consult with a coding specialist.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: The relative value units (RVUs) for this code vary based on geographic location, facility type, and other factors.Consult the appropriate fee schedules for current values.
- Global Days : The global period for this surgery will vary depending on payer and local practice.Check with the payer for specific guidelines.
- Payment Status: Active
- Modifier TC rule: Technical component (TC) modifiers are not typically applicable to this code.The professional component (PC) is usually included.
- Fee Schedule : Historical fee schedule data varies by payer and location. Consult payer-specific fee schedules for historical information.
- Specialties:Otolaryngology
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Office