2025 CPT code 69641
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Auditory System Surgery Feed
Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, and tympanic membrane repair); without ossicular chain reconstruction.
Modifiers may apply depending on the circumstances of the procedure (e.g., 50 for bilateral procedures, 59 for distinct procedural services).Consult the CPT manual for modifier usage guidelines.
Medical necessity is established by the presence of a perforated eardrum, chronic otitis media, cholesteatoma, or other conditions requiring surgical intervention. Documentation supporting the diagnosis and the need for the procedure should be present.
The otolaryngologist (ENT surgeon) is responsible for the surgical procedure and postoperative care.Anesthesiologist involvement is also necessary.
In simple words: This surgery repairs a damaged eardrum and removes infected or diseased bone behind the eardrum.It may also involve rebuilding parts of the ear canal.The tiny bones in the middle ear are not repaired during this procedure.
This procedure involves the surgical repair of the tympanic membrane (eardrum) and the removal of all or a portion of the mastoid bone.It may include reconstruction of the ear canal, tympanic membrane repair, and other middle ear surgeries.Reconstruction of the ossicular chain is explicitly excluded.
Example 1: A patient presents with chronic otitis media and a perforated tympanic membrane. The surgeon performs a 69641 to repair the eardrum and remove infected mastoid cells., A patient with a cholesteatoma (benign growth) behind the eardrum undergoes a 69641 to remove the cholesteatoma and repair the damaged tympanic membrane., A patient with recurrent ear infections and mastoiditis undergoes a 69641. The procedure includes mastoidectomy to remove infected bone, canalplasty to reconstruct the ear canal, and tympanoplasty to repair the eardrum.
Preoperative and postoperative evaluations, including audiograms, imaging (CT scan of the temporal bone), operative report detailing the surgical technique, and pathology results (if applicable) are necessary for appropriate documentation.
** This code does not include ossicular chain reconstruction.If ossicular chain reconstruction is performed, a different CPT code should be used (e.g., 69644 or 69646).
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: RVUs are not provided in the source data. Consult current Medicare Physician Fee Schedule or other relevant payment schedules for the most up-to-date information.
- Global Days : Global period details are not specified in the provided source data. The global period may vary based on payer and local guidelines.Consult appropriate billing guidelines.
- Payment Status: Active
- Modifier TC rule: No information is available regarding the application of a technical component (TC) modifier for this code from the source.
- Fee Schedule : Historical fee schedule information is not available in the source.
- Specialties:Otolaryngology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center