L29224-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Mastoidectomy Cavity Debridement (L29224)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29224

LCD Title Mastoidectomy Cavity Debridement

Contractor's Determination Number 69220

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: N/A

Indications and Limitations of Coverage and/or Medical Necessity

A mastoidectomy cavity is created as a result of ear operations such as radical mastoidectomy, modified radical mastoidectomy, atticotomy, fenestration operation, temporal bone resection, etc. Such operations are performed to eradicate disease of the middle ear and mastoid. An automastoidectomy may also occur as a result of a cholesteatoma. Complications may occur postoperatively or any time after the creation of the cavity and necessitate debridement of the cavity.

Medicare will consider the debridement of the mastoidectomy cavity medically reasonable and necessary under the following circumstances:

For patients who have undergone any of the following surgical procedures: a radical mastoidectomy, a modified mastoidectomy, atticotomy, fenestration operation, temporal bone resection, or developed an automastoidectomy (as a result of cholesteatoma), resulting in the formation of a mastoid cavity, and present with any of the following signs/symptoms:

• Persistent earache

• Ear drainage

• Excess crusting

• Ear pressure

• New onset of hearing loss

• Dizziness

• New onset of facial muscle weakness

Simple debridement (69220)

A simple debridement of the mastoidectomy cavity (routine cleaning) is considered medically reasonable and necessary for those presenting with dry debris or excess crusting of the mastoidectomy cavity. It is generally expected that a simple debridement of the mastoidectomy cavity would be performed no more than once every three months. However, the frequency at which a simple debridement of the mastoidectomy cavity is performed is dependent on the clinical presentation of the individual patient.

Complex debridement (69222)

A complex debridement of the mastoidectomy cavity is considered medically reasonable and necessary for those presenting with any of the following conditions: lack of previous meatoplasty or stenosis of the ear canal, bleeding, recurrent cholesteatoma, granulation tissue, presence of labyrinthine fistula, absence of tympanic membrane, active infection, inadequate lowering of the facial ridge, presence of cholesteral granuloma cysts, severe pain, severe vertigo or increased vertigo during debridement, or an uncooperative patient (e.g., young child).

The frequency at which a complex debridement of the mastoidectomy cavity is performed is dependent on the clinical presentation of the individual patient. For example, debridement of the mastoidectomy cavity may be required on multiple visits at close intervals due to inter-current infection and the attempt to reduce mucolized surfaces and remove granulomatous tissue.

Note: It is inappropriate to bill either procedure code 69220 or 69222 for removal of impacted cerumen or debridement of the external auditory canal.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Reenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

69220 DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPLE (EG, ROUTINE CLEANING)

69222 DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX (EG, WITH ANESTHESIA OR MORE THAN ROUTINE CLEANING)

ICD-9 Codes that Support Medical Necessity

381.00 - 381.03

381.10 - 381.19

381.20 - 381.29

ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED - ACUTE SANGUINOUS OTITIS MEDIA

CHRONIC SEROUS OTITIS MEDIA SIMPLE OR UNSPECIFIED - OTHER CHRONIC SEROUS OTITIS MEDIA

CHRONIC MUCOID OTITIS MEDIA SIMPLE OR UNSPECIFIED - OTHER CHRONIC MUCOID OTITIS MEDIA

381.3 OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA

382.1 - 382.01 ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM ACUTE SUPPURATIVE OTITIS MEDIA WITH SPONTANEOUS RUPTURE OF EARDRUM

382.2 CHRONIC TUBOTYMPANIC SUPPURATIVE OTITIS MEDIA

382.3 CHRONIC ATTICOANTRAL SUPPURATIVE OTITIS MEDIA

382.4 UNSPECIFIED CHRONIC SUPPURATIVE OTITIS MEDIA

382.5 UNSPECIFIED SUPPURATIVE OTITIS MEDIA

382.9 UNSPECIFIED OTITIS MEDIA

383.1 - 383.02 ACUTE MASTOIDITIS WITHOUT COMPLICATIONS - ACUTE MASTOIDITIS WITH OTHER COMPLICATIONS

383.2 CHRONIC MASTOIDITIS

383.30 - 383.33

385.30 - 385.9

POSTMASTOIDECTOMY COMPLICATION UNSPECIFIED - GRANULATIONS OF POSTMASTOIDECTOMY CAVITY

CHOLESTEATOMA UNSPECIFIED - UNSPECIFIED DISORDER OF MIDDLE EAR AND MASTOID

386.19 OTHER PERIPHERAL VERTIGO

386.40 - 386.48 LABYRINTHINE FISTULA UNSPECIFIED - LABYRINTHINE FISTULA OF COMBINED SITES

387.9 OTOSCLEROSIS UNSPECIFIED

388.60 - 388.69 OTORRHEA UNSPECIFIED - OTHER OTORRHEA

388.70 - 388.72 OTALGIA UNSPECIFIED - REFERRED OTOGENIC PAIN

389.00 CONDUCTIVE HEARING LOSS UNSPECIFIED

389.03 CONDUCTIVE HEARING LOSS MIDDLE EAR

389.5 CONDUCTIVE HEARING LOSS, UNILATERAL

389.6 CONDUCTIVE HEARING LOSS, BILATERAL

389.08 CONDUCTIVE HEARING LOSS OF COMBINED TYPES

389.10 SENSORINEURAL HEARING LOSS UNSPECIFIED

389.11 SENSORY HEARING LOSS, BILATERAL

389.12 NEURAL HEARING LOSS, BILATERAL

389.13 NEURAL HEARING LOSS, UNILATERAL

389.15 SENSORINEURAL HEARING LOSS, UNILATERAL

389.16 SENSORINEURAL HEARING LOSS, ASYMMETRICAL

389.17 SENSORY HEARING LOSS, UNILATERAL

389.18 SENSORINEURAL HEARING LOSS, BILATERAL

389.20 - 389.22 MIXED HEARING LOSS, UNSPECIFIED - MIXED HEARING LOSS, BILATERAL

389.8 OTHER SPECIFIED FORMS OF HEARING LOSS

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation (e.g., office/progress notes, procedure notes) maintained by the performing provider must indicate the medical necessity for performing the service. It is expected that the following information will be clearly documented in the medical record to support the mastoidectomy cavity debridement code billed:

• Documentation of previous radical mastoidectomy, modified radical mastoidectomy, atticotomy, fenestration operation, temporal bone resection or development of an automastoidectomy (as a result of a cholesteatoma);

• the extent of the current disease pathology necessitating debridement; and

• the method utilized for debridement, including any anesthesia (when applicable).

Appendices

Utilization Guidelines The frequency at which a debridement of the mastoidectomy cavity is performed is dependent on the clinical presentation of the patient. However, it is generally expected that a simple debridement of the mastoidectomy cavity would be performed no more than once every three months.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for

medical necessity.

Sources of Information and Basis for Decision

American Academy of Otolaryngology-Head and Neck Surgery. (2002). Cholesteatoma. Retrieved from the World Wide Web on March 6, 2002 at http://www.ENTNet/healthinfo/ears/cholesteatoma.cfm This source provided the information regarding cholesteatoma.

Ballenger, J.J. & Snow Jr., J.B. (Eds.). (1996). Otorhinolaryngology: Head and neck surgery (15th ed.). Baltimore: Williams & Wilkins. This source provided the description for radical mastoidectomy.

American Academy of Otolaryngology-Head and Neck Surgery. (2002). Mastoidectomy. Retrieved from the World Wide Web on March 6, 2002 at http://www.entlink.net/practice/indicators/mastoidectomy.html This source provided information regarding the complications that may occur post mastoidectomy procedure.

Roland, P.S. (2002). Cholesteatoma. Retrieved from the World Wide Web on March 28, 2002 at http://www.emedicine.com/ped/topic384.htm This source provided the statement regarding the utilization of this

procedure. Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in

cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29224) replaces LCD L5927 as the policy in notice. This document (L29224) is effective on 02/02/2009.

Reason for Change