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Official Description

Revision mastoidectomy; resulting in modified radical mastoidectomy

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

A revision mastoidectomy is a surgical procedure aimed at addressing complications related to the mastoid air cells, which are small, air-filled spaces located within the mastoid process of the temporal bone, situated behind the ear. This procedure is specifically indicated for patients who have experienced recurrent infections or other issues that necessitate the removal of infected or diseased tissue within the mastoid area. During the surgery, an incision is made behind the ear to access the mastoid bone, allowing the surgeon to inspect the remaining mastoid air cells and determine the extent of the necessary revision. The goal of the revision mastoidectomy is to effectively manage conditions such as recurrent cholesteatoma, which is an abnormal skin growth in the middle ear that can lead to further complications if not treated. The procedure can vary in its extent, resulting in either a modified radical mastoidectomy or a radical mastoidectomy, depending on the severity of the condition and the structures involved. In the case of a modified radical mastoidectomy, the procedure preserves critical structures such as the tympanic membrane and middle ear components while removing the infected air cells and parts of the external auditory canal to facilitate proper drainage and healing.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The revision mastoidectomy is performed for specific indications related to the health and functionality of the ear and surrounding structures. The following conditions may warrant this surgical intervention:

  • Recurrent Cholesteatoma - A condition characterized by the abnormal growth of skin cells in the middle ear, which can lead to infection and damage to surrounding structures.
  • Infected Mastoid Air Cells - Presence of infection within the mastoid air cells that may not have responded to medical treatment, necessitating surgical removal.
  • Chronic Ear Infections - Ongoing infections that affect the middle ear and mastoid area, leading to complications that require surgical intervention.

2. Procedure

The procedure for a revision mastoidectomy involves several critical steps to ensure effective removal of infected tissue and preservation of vital structures. The following outlines the procedural steps:

  • Step 1: Anesthesia Administration - The patient is placed under general anesthesia to ensure comfort and immobility during the procedure.
  • Step 2: Incision - A surgical incision is made behind the ear to provide access to the mastoid process. This incision is carefully placed to minimize scarring and facilitate healing.
  • Step 3: Exposure of Mastoid Bone - The surgeon carefully dissects through the soft tissue to expose the mastoid bone, allowing for a clear view of the mastoid air cells.
  • Step 4: Inspection of Mastoid Air Cells - The remaining mastoid air cells are thoroughly inspected to assess the extent of infection and determine the necessary surgical intervention.
  • Step 5: Removal of Infected Tissue - In cases of modified radical mastoidectomy, the surgeon removes the infected mastoid air cells while preserving the tympanic membrane and middle ear structures. The posterior and superior walls of the external auditory canal may also be removed to enhance exposure.
  • Step 6: Drain Placement - A drain may be placed to facilitate continued drainage of any residual fluid or debris, promoting healing and reducing the risk of complications.
  • Step 7: Closure - Once the procedure is complete, the incision is closed in layers, and the area is dressed appropriately to support recovery.

3. Post-Procedure

After the revision mastoidectomy, patients are typically monitored for any immediate complications. Post-procedure care may include pain management, instructions for wound care, and follow-up appointments to assess healing. Patients may experience some swelling and discomfort, which is expected and can be managed with prescribed medications. It is essential to follow the surgeon's guidelines regarding activity restrictions and signs of potential complications, such as increased pain, fever, or drainage from the incision site. Full recovery may take several weeks, during which time patients should avoid activities that could strain the surgical site.

Short Descr REV MSTDC RSLT MOD RAD MSTDC
Medium Descr REVJ MASTOIDECTOMY RSLTG MODF RAD MSTDC
Long Descr Revision mastoidectomy; resulting in modified radical 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
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).
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)
Date
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2025-01-01 Changed Short Description changed.
Pre-1990 Added Code added.
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