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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 operation is indicated for patients suffering from chronic ear infections, cholesteatoma, or other conditions that compromise the integrity of the middle ear and surrounding structures. The procedure may involve additional techniques such as canalplasty, which is the widening of the ear canal, and middle ear surgery to address any abnormalities or damage within the ear. The classification of tympanoplasties is based on the extent of the repair needed; in this case, the procedure is categorized as a radical or complete mastoidectomy, which entails a significant removal of mastoid bone to create a single cavity that encompasses both the mastoid and the ear canal. The surgical approach typically involves an incision behind the ear to access the mastoid bone, allowing for thorough inspection and removal of any infected tissue, debris, and purulent matter. The goal of this procedure is to restore hearing, eliminate infection, and prevent future complications while ensuring the structural integrity of the ear is maintained.
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The tympanoplasty with mastoidectomy procedure is indicated for the following conditions:
The procedure involves several critical steps to ensure effective treatment of the ear condition:
After the tympanoplasty with mastoidectomy, patients are typically monitored for any immediate complications. Post-operative care may include pain management, instructions for keeping the ear dry, and follow-up appointments to assess healing. Patients may experience some swelling and discomfort, which is expected as part of the recovery process. It is essential to follow the surgeon's guidelines regarding activity restrictions and care of the surgical site to ensure optimal healing and prevent infection.
| Short Descr | REVISE MIDDLE EAR & MASTOID | Medium Descr | TYMPANOPLASTY MASTOIDECTOMY RAD/COMPL W/O OCR | Long Descr | Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without 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 |
| LT | Left side (used to identify procedures performed on the left side of the body) | 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. | 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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