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A labyrinthectomy is a surgical procedure that involves the removal of the inner ear, also known as the labyrinth, which is a complex structure located within the petrous portion of the temporal bone. The labyrinth is composed of two main layers: the bony labyrinth, which provides a rigid outer structure, and the membranous labyrinth, which contains the sensory organs responsible for balance and hearing. The labyrinth is further divided into specific areas, including the vestibule, cochlea, and semicircular canals, each playing a crucial role in the body's equilibrium and auditory functions. This procedure is primarily indicated for patients suffering from Meniere's disease, a condition characterized by episodes of vertigo, tinnitus, and hearing loss. The labyrinthectomy effectively alleviates symptoms by excising the inner ear structures that contribute to balance disturbances. It is important to note that this procedure is only performed on patients who have little to no residual hearing in the affected ear, as the removal of the inner ear structures results in complete deafness in that ear. The surgical approach for this procedure can vary; for CPT® Code 69910, the transmastoid approach is utilized, which involves making an incision behind the ear to access the mastoid bone and subsequently the inner ear, allowing for the complete excision of both the bony and membranous labyrinth.
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The labyrinthectomy procedure is indicated for specific conditions and symptoms that necessitate surgical intervention. The following are the primary indications for performing a labyrinthectomy:
The labyrinthectomy procedure involves several critical steps to ensure successful access and removal of the inner ear structures. The following outlines the procedural steps involved in CPT® Code 69910:
After the labyrinthectomy procedure, patients typically require careful monitoring and post-operative care. Expected recovery may involve managing pain and discomfort at the incision site, as well as monitoring for any potential complications such as infection or bleeding. Patients may experience immediate relief from vertigo symptoms, but it is essential to note that complete deafness in the affected ear will occur as a result of the procedure. Follow-up appointments will be necessary to assess healing and address any concerns that may arise during the recovery process. Additionally, patients may be advised on rehabilitation strategies to help adjust to changes in balance and hearing.
| Short Descr | REMOVE INNER EAR & MASTOID | Medium Descr | LABYRINTHECTOMY W/MASTOIDECTOMY | Long Descr | Labyrinthectomy; with 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. | 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. | 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.) | 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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| Pre-1990 | Added | Code added. |
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