Coding Ahead
CasePilot
Medical Coding Assistant
Case2Code
Search and Code Lookup Tool
CareerCenter
Medical Coding Job Board
Log in Register free account

Need help choosing the right code?

Ask CasePilot about procedures, modifiers, bundling, and coding guidance.

Try CasePilot

Official Description

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (eg, postfenestration)

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

A tympanoplasty without mastoidectomy is a surgical procedure aimed at repairing the tympanic membrane (eardrum) and, in some cases, reconstructing the ossicular chain, which consists of the small bones in the middle ear. This procedure can be performed as an initial surgery or as a revision of a previous tympanoplasty. The surgery may involve additional techniques such as canalplasty, which is the widening of the ear canal, and atticotomy, which is the surgical opening of the attic of the middle ear. The classification of tympanoplasties is based on whether the repair is limited to the tympanic membrane alone or if it also includes the ossicles, which are critical for sound transmission. In this procedure, the surgeon may access the middle ear through the ear canal or via a post-auricular incision, which is made behind the ear. If the external auditory canal is narrowed due to recurrent infections, a canalplasty is performed to enlarge it. The surgeon inspects the tympanic membrane and the middle ear structures, removing any scar tissue that may be present. If necessary, the attic of the middle ear is accessed through an atticotomy, which may involve removing a thin layer of bone known as the scutum or drilling into the bony ear canal for a larger access. The surgical technique includes preparing the edges of the tympanic membrane hole to promote healing, which may involve rimming the edges until bleeding occurs. Depending on the size and location of the perforation, a patch may be required. Tissue grafts, which can be made from skin, fat, tendon, or fascia, are harvested and prepared for placement over the perforation. An absorbable sponge may be used to support the graft in the middle ear. If canalplasty is performed, skin grafts are also placed over the exposed bone in the ear canal. Finally, the ear is packed with gauze to support the surgical site during the healing process. In cases where ossicular chain reconstruction is indicated, the surgeon inspects the ossicles and reconstructs them using harvested tissue grafts, ensuring proper function of the middle ear. This comprehensive approach aims to restore hearing and prevent further complications associated with ear conditions.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The tympanoplasty without mastoidectomy with ossicular chain reconstruction is indicated for various conditions affecting the tympanic membrane and the ossicular chain. The following are the explicitly provided indications for this procedure:

  • Perforated Tympanic Membrane - A hole or tear in the tympanic membrane that may result from infection, trauma, or chronic ear disease.
  • Chronic Otitis Media - Persistent inflammation or infection of the middle ear that can lead to tympanic membrane perforation and ossicular damage.
  • Ossicular Chain Dysfunction - Malfunction or damage to the ossicles (incus, malleus, stapes) that may impair hearing and require reconstruction.
  • Recurrent Ear Infections - Frequent episodes of ear infections that may necessitate surgical intervention to prevent further complications.
  • Previous Tympanoplasty Failure - Revision surgery may be required if a prior tympanoplasty did not achieve the desired outcome or if complications arose.

2. Procedure

The procedure for tympanoplasty without mastoidectomy with ossicular chain reconstruction involves several detailed steps, as outlined below:

  • Step 1: Anesthesia and Preparation - The patient is placed under general anesthesia or local anesthesia with sedation. The surgical site is prepared and draped to maintain a sterile environment.
  • Step 2: Accessing the Middle Ear - The surgeon may access the middle ear through the ear canal or via a post-auricular incision, depending on the specific case and the extent of the surgery required.
  • Step 3: Canalplasty (if indicated) - If the external auditory canal is stenosed, a canalplasty is performed to widen the canal. This involves using a drill to remove bone and increase the diameter of the canal.
  • Step 4: Inspection and Preparation of the Tympanic Membrane - The tympanic membrane is inspected, and any scar tissue in the middle ear is removed. The edges of the perforation are prepared by rimming until bleeding occurs to promote healing.
  • Step 5: Atticotomy (if indicated) - If necessary, the attic of the middle ear is accessed through an atticotomy, which may involve removing the scutum or drilling into the bony ear canal.
  • Step 6: Graft Harvesting and Preparation - Tissue grafts are harvested from the patient, which may include skin, fat, tendon, or fascia. The graft is prepared for placement over the tympanic membrane perforation.
  • Step 7: Graft Placement - The graft is placed over the hole in the tympanic membrane. If canalplasty was performed, skin grafts are also placed over the exposed bone in the external auditory canal.
  • Step 8: Ossicular Chain Reconstruction (if indicated) - The ossicles are inspected, and if reconstruction is necessary, tissue grafts are used to reconstruct the incus, malleus, and/or stapes. This may involve using a partial or total ossicular replacement prosthesis if indicated.
  • Step 9: Packing and Closure - An absorbable sponge is placed in the ear canal over the tympanic membrane graft to hold it in place. The ear is then packed with gauze, and the incision is closed if a post-auricular approach was used.

3. Post-Procedure

After the tympanoplasty without mastoidectomy with ossicular chain reconstruction, the patient is monitored in a recovery area until the effects of anesthesia wear off. Post-operative care includes instructions for keeping the ear dry and avoiding water exposure during the initial healing period. Pain management may be provided as needed, and follow-up appointments are scheduled to assess healing and the success of the procedure. Patients are advised to report any signs of infection, such as increased pain, fever, or drainage from the ear. The expected recovery time may vary, but patients can generally expect gradual improvement in hearing as the graft heals and the middle ear structures stabilize.

Short Descr REBUILD EARDRUM STRUCTURES
Medium Descr TYMPNOPLSTY W/O MSTDC 1ST/REVJ W/OSICLE RECNSTJ
Long Descr Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (eg, postfenestration)
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) 1 - Statutory 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) P5E - Ambulatory procedures - other
MUE 1
CCS Clinical Classification 22 - Tympanoplasty
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).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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)
SG Ambulatory surgical center (asc) facility service
Date
Action
Notes
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"