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A mastoidectomy is a surgical procedure aimed at removing infected mastoid air cells, which are small, air-filled spaces located within the mastoid process, a bony structure situated behind the ear that projects from the temporal bone of the skull. The procedure is typically indicated in cases of acute infection, where the mastoid bone becomes compromised due to the presence of infection. During the surgery, an incision is made behind the ear to expose the mastoid bone, allowing the surgeon to access and remove the infected tissue. The radical mastoidectomy, specifically identified by CPT® Code 69511, is performed in cases of extensive cholesteatoma, a destructive and expanding growth that can lead to further complications if not addressed. This procedure involves the complete removal of the mastoid air cell system, along with any purulent matter and debris. Unlike a modified radical mastoidectomy, which preserves certain structures of the middle ear, a radical mastoidectomy entails the removal of additional anatomical components, including the head of the malleus and the body of the incus, and may also involve the stapes, although efforts are made to preserve it when possible. This extensive approach allows for the effective exteriorization of the mastoid cavity and middle ear, facilitating better drainage and management of the infection.
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The radical mastoidectomy (CPT® Code 69511) is indicated for the following conditions:
The radical mastoidectomy involves several critical procedural steps, which are detailed as follows:
After the radical mastoidectomy, patients typically require careful monitoring and follow-up care. Post-procedure care may include the placement of a drain to facilitate continued drainage of any remaining fluid or debris. Patients are advised on signs of infection or complications that may arise during the recovery period. The expected recovery time can vary, and patients may need to avoid certain activities that could strain the surgical site. Regular follow-up appointments are essential to assess healing and ensure that the infection has been adequately managed.
| Short Descr | EXTENSIVE MASTOID SURGERY | Medium Descr | MASTOIDECTOMY RADICAL | Long Descr | Mastoidectomy; radical | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 24 - Mastoidectomy |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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