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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. It may involve additional techniques such as canalplasty, which is the widening of the ear canal, atticotomy, which is the surgical opening of the tympanic attic, and/or other middle ear surgeries. The classification of tympanoplasties is based on whether the surgery focuses solely on repairing the tympanic membrane or if it also addresses the ossicles. In contrast to CPT® Code 69631, which involves tympanoplasty without ossicular chain reconstruction, CPT® Code 69633 specifically includes the reconstruction of the ossicular chain using a synthetic prosthesis, such as a partial ossicular replacement prosthesis (PORP) or a total ossicular replacement prosthesis (TORP). The procedure can be accessed through the ear canal or via a post-auricular incision, depending on the specific needs of the patient. If the external auditory canal is narrowed due to recurrent infections, a canalplasty is performed to enhance access. The surgical process includes inspecting the tympanic membrane and middle ear structures, removing any scar tissue, and preparing a graft to cover the tympanic membrane defect. The use of absorbable materials helps support the graft during the healing process, ensuring optimal recovery and restoration of hearing function.
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The tympanoplasty without mastoidectomy procedure is indicated for various conditions affecting the tympanic membrane and ossicular chain. The following are explicitly provided indications for this procedure:
The procedure for tympanoplasty without mastoidectomy with ossicular chain reconstruction involves several detailed steps:
After the tympanoplasty procedure, patients are typically monitored for any immediate complications. Post-procedure care may include instructions for keeping the ear dry and avoiding water exposure to prevent infection. Patients may experience some discomfort, which can be managed with prescribed pain relief. Follow-up appointments are essential to assess the healing of the tympanic membrane and the success of the ossicular chain reconstruction. The expected recovery time can vary, but patients are generally advised to avoid strenuous activities for a specified period to ensure proper healing.
| Short Descr | REBUILD EARDRUM STRUCTURES | Medium Descr | TYMPANOPLASTY W/O MASTOIDEC 1ST/REVJ PROSTH TORP | Long Descr | Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP]) | 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). | 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.) | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | 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 |
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| 2009-01-01 | Changed | Code description changed |
| Pre-1990 | Added | Code added. |
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