Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
A revision mastoidectomy is a surgical procedure aimed at addressing complications arising from previous mastoid surgeries, specifically to remove infected mastoid air cells. The mastoid process, which is a bony structure located behind the ear, is an extension of the temporal bone of the skull. Within this bony area, there are numerous mastoid air cells that can become infected, leading to various ear-related health issues. During the procedure, a surgical incision is made behind the ear to expose the mastoid bone. The surgeon then inspects the remaining mastoid air cells to assess the extent of infection and determine the necessary surgical intervention. In the case of CPT® Code 69601, the revision results in a complete mastoidectomy, which involves the total removal of the air cell system along with any purulent matter, debris, and infected tissue present. This procedure is typically indicated for acute infections that have not responded to other treatments. Additionally, a drain may be placed post-operatively to facilitate continued drainage of any residual fluid or infection. This procedure is critical for restoring ear health and preventing further complications associated with chronic mastoid infections.
© Copyright 2026 Coding Ahead. All rights reserved.
The revision mastoidectomy, specifically coded as CPT® 69601, is indicated for the following conditions:
The procedure for a revision mastoidectomy resulting in a complete mastoidectomy involves several critical steps:
Post-procedure care for a revision mastoidectomy includes monitoring for any signs of infection, managing pain, and ensuring proper drainage through the placed drain. Patients are typically advised to follow up with their healthcare provider to assess healing and to remove the drain when appropriate. Recovery may vary depending on the individual, but patients can expect some swelling and discomfort in the initial days following the surgery. It is essential to adhere to any prescribed post-operative instructions to promote optimal recovery and prevent complications.
| Short Descr | REVJ MSTDC RSLTG COMPL MSTDC | Medium Descr | REVJ MASTOIDECTOMY RSLTG COMPL MASTOIDECTOMY | Long Descr | Revision mastoidectomy; resulting in complete mastoidectomy | 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 |
| 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | 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) | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.