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2025 CPT code 69801

Labyrinthotomy with perfusion of vestibuloactive drug(s), transcanal.

Code 69801 should only be reported once per day, regardless of the number of injections performed that day.The medication should be reported separately using an appropriate HCPCS code.Documentation must support the medical necessity and accurate reporting of the procedure and medication.

Modifiers 50 (bilateral procedure) and potentially others may apply depending on the specific circumstances of the procedure. Consult the AMA CPT codebook or other authoritative sources for modifier guidance.

Medical necessity for 69801 is established by the presence of an inner ear condition requiring treatment with vestibuloactive drugs.This might include Meniere's disease, sudden sensorineural hearing loss, or other conditions causing vertigo or hearing loss unresponsive to conservative management.The choice of transtympanic injection over other treatments must be clinically justified, and the type of drug selected must be appropriate for the patient’s condition.

The otolaryngologist is responsible for performing the surgical procedure, including making the incision, administering the medication, and closing the incision. Post-operative care and follow-up are also the responsibility of the otolaryngologist.

IMPORTANT This code should not be reported more than once per day. It should also not be reported with codes 69420, 69421, 69433, or 69436 if performed on the same ear.The injected medication should be reported separately using an HCPCS code (e.g., J codes for various steroids and aminoglycosides).

In simple words: This code describes surgery on the inner ear where the doctor makes a small incision, injects medicine (like steroids or antibiotics), and then closes the incision. The medicine helps with inner ear problems like dizziness or hearing loss. The injected medication is billed separately.

This CPT code encompasses a surgical procedure involving a transcanal labyrinthotomy with the perfusion of one or more vestibuloactive drugs into the inner ear.The procedure may involve an incision into the posterior ear canal skin, reflection of the skin flap and posterior tympanic membrane, visualization of the horizontal semicircular canal, and instillation of drugs (such as steroids or aminoglycosides) into the middle ear under microscopic guidance.The incision is then repaired with sutures. Alternatively, a transtympanic injection with a needle may be used to instill the drugs.The code includes the tube placement and has a zero-day global period. The medication is billed separately using an HCPCS code.

Example 1: A patient presents with severe vertigo consistent with Meniere's disease.The physician performs a transtympanic injection of gentamicin into the affected ear using code 69801.The gentamicin is billed separately with an HCPCS code., A patient experiences sudden sensorineural hearing loss. The physician administers a transtympanic injection of dexamethasone into the affected ear as a treatment option. Code 69801 is used to report the procedure, with the dexamethasone billed separately., A patient presents with chronic Meniere's disease and has multiple transtympanic injections of steroids scheduled over several days. 69801 is reported on each day of treatment with the drug reported separately using the J code for the medication.

Complete medical history and physical examination, including an assessment of the patient’s hearing and balance. Detailed documentation should include the type and amount of medication used, the method of injection (transcanal or transtympanic), and any intraoperative complications or findings.Pre-operative and post-operative audiograms should be documented to assess treatment effectiveness. Operative notes should be thorough and clearly delineate the procedure performed.

** Careful documentation is crucial for accurate coding and reimbursement.Always refer to the latest CPT and HCPCS codebooks and guidelines for the most up-to-date information.Any discrepancies between the provided description and official guidelines should be resolved by consulting the relevant authoritative sources.

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