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 the infection and determine the necessary surgical intervention. In the context of CPT® Code 69603, the revision mastoidectomy results in a radical mastoidectomy, which is indicated for cases involving recurrent extensive cholesteatoma. This procedure involves the complete removal of the mastoid air cell system, along with any purulent matter, debris, and infected tissue. The surgical approach is similar to that of a modified radical mastoidectomy, but it also includes the removal of critical structures within the epitympanum, such as the head of the malleus and the body of the incus, which are essential components of the middle ear. The stapes may also be removed during this procedure, although efforts are made to preserve it when possible. This comprehensive approach allows for the effective exteriorization of the mastoid cavity and the middle ear, facilitating better management of the underlying condition.
© Copyright 2026 Coding Ahead. All rights reserved.
The revision mastoidectomy resulting in a radical mastoidectomy, as described by CPT® Code 69603, is indicated for specific conditions related to chronic ear infections and cholesteatoma. The following are the primary indications for this procedure:
The procedure for a revision mastoidectomy resulting in a radical mastoidectomy involves several critical steps to ensure the effective removal of infected tissue and restoration of ear health. The following outlines the procedural steps:
After the completion of the radical mastoidectomy, patients typically require careful monitoring and follow-up care. Post-procedure care may include pain management, instructions for wound care, and the importance of keeping the surgical site clean and dry. Patients may also be advised on activity restrictions to promote healing. Follow-up appointments are essential to assess the surgical site, monitor for any signs of infection, and evaluate the success of the procedure. The expected recovery time can vary based on individual circumstances, but patients should be informed about potential symptoms such as drainage from the ear, which may be normal in the initial recovery phase. Any concerns regarding unusual symptoms should be promptly addressed with the healthcare provider.
| Short Descr | REVJ MSTDC RSLTG RAD MSTDC | Medium Descr | REVJ MASTOIDECTOMY RSLTG RAD MASTOIDECTOMY | Long Descr | Revision mastoidectomy; resulting in 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. | 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) | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.