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 with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

A tympanoplasty with mastoidectomy is a surgical procedure that combines the repair of the tympanic membrane (eardrum) with the removal of infected or diseased mastoid bone. This procedure is performed when there is a need to address issues within the middle ear and mastoid area, particularly when the canal wall is either intact or has been reconstructed. The tympanoplasty aspect focuses on repairing the tympanic membrane, which may involve the reconstruction of the ossicular chain, the series of small bones in the middle ear that are crucial for hearing. The procedure may also include canalplasty, which is the widening of the external auditory canal, especially in cases where the canal has become narrowed due to repeated infections. During the surgery, an incision is typically made behind the ear to access the mastoid bone, allowing the surgeon to inspect the mastoid air cells and determine the extent of the disease. The procedure involves the removal of any infected tissue, debris, and purulent matter from the mastoid air cells. If necessary, the walls of the external auditory canal may be reconstructed after the mastoidectomy. The tympanic membrane is then repaired, which may involve techniques such as rimming the edges of the perforation or using a graft to cover larger holes. The overall goal of this procedure is to restore hearing and prevent future infections by addressing both the tympanic membrane and the underlying structures of the ear.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The tympanoplasty with mastoidectomy procedure is indicated for various conditions affecting the middle ear and mastoid area. These include:

  • Chronic Otitis Media: Persistent inflammation or infection of the middle ear that may lead to tympanic membrane perforation and ossicular chain dysfunction.
  • Mastoiditis: Infection of the mastoid bone, often resulting from untreated or severe otitis media.
  • Tympanic Membrane Perforation: A hole or tear in the eardrum that can cause hearing loss and increase the risk of ear infections.
  • Ossicular Chain Disruption: Damage or dislocation of the small bones in the middle ear, which may require reconstruction to restore hearing.
  • Cholesteatoma: An abnormal skin growth in the middle ear that can erode bone and disrupt normal ear function.

2. Procedure

The tympanoplasty with mastoidectomy procedure involves several detailed steps to ensure effective treatment of the ear conditions. The following procedural steps are typically performed:

  • Step 1: Incision and Exposure An incision is made behind the ear to access the mastoid bone. This allows the surgeon to expose the mastoid air cells and assess the extent of the disease.
  • Step 2: Inspection and Debridement The mastoid air cells are inspected, and any infected tissue, debris, or purulent matter is carefully removed to clear the area and prevent further infection.
  • Step 3: Canal Wall Reconstruction If the posterior and superior walls of the external auditory canal are removed during the procedure, they are reconstructed to restore the integrity of the canal.
  • Step 4: Canalplasty (if necessary) If the external auditory canal is stenosed due to repeated infections, a canalplasty is performed using a drill to remove bone and increase the diameter of the canal.
  • Step 5: Tympanic Membrane Repair The hole in the tympanic membrane is exposed and inspected. Scar tissue in the middle ear is removed, and the tympanic membrane is repaired using techniques such as rimming the edges or applying a graft for larger perforations.
  • Step 6: Graft Preparation and Placement Tissue grafts are harvested, and absorbable sponge material may be placed in the middle ear to support the graft. The graft is then positioned over the hole in the tympanic membrane.
  • Step 7: Ossicular Chain Reconstruction (if indicated) If the ossicular chain requires reconstruction, the surgeon inspects the ossicles and determines which bones (incus, malleus, and/or stapes) need to be reconstructed. Tissue grafts are harvested and used for this reconstruction.
  • Step 8: Packing and Closure An absorbable sponge is placed in the ear canal over the tympanic membrane graft to hold it in place, and the ear is packed with gauze to support healing.

3. Post-Procedure

After the tympanoplasty with mastoidectomy, patients are typically monitored for any immediate complications. Post-procedure care may include instructions for keeping the ear dry and avoiding water exposure during the healing process. Patients may experience some discomfort, which can be managed with prescribed pain medications. Follow-up appointments are essential to assess the healing of the tympanic membrane and the success of the ossicular chain reconstruction, if performed. The expected recovery time can vary, but patients are generally advised to avoid strenuous activities and heavy lifting for a specified period to ensure proper healing.

Short Descr REVISE MIDDLE EAR & MASTOID
Medium Descr TMPP MASTOIDECT NTC/RCNSTED CANAL WALL OCR
Long Descr Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction
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 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).
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.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, 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)
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"