LCD/NCD Portal

L29224 MASTOIDECTOMY CAVITY DEBRIDEMENT

 

 

02/02/2009

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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:

o a radical mastoidectomy,

o a modified mastoidectomy,

o atticotomy,

o fenestration operation,

o temporal bone resection, or

o 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)

o 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.

o It is generally expected that a simple debridement of the mastoidectomy cavity would be performed no more than once every three months.

o 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)

o 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).

o 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.

 

 

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 ACUTE NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED

381.01 ACUTE SEROUS OTITIS MEDIA

381.02 ACUTE MUCOID OTITIS MEDIA

381.03 ACUTE SANGUINOUS OTITIS MEDIA

381.10 CHRONIC SEROUS OTITIS MEDIA SIMPLE OR UNSPECIFIED

381.19 OTHER CHRONIC SEROUS OTITIS MEDIA

381.20 CHRONIC MUCOID OTITIS MEDIA SIMPLE OR UNSPECIFIED

381.29 OTHER CHRONIC MUCOID OTITIS MEDIA

381.3 OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA

382.00 ACUTE SUPPURATIVE OTITIS MEDIA WITHOUT SPONTANEOUS RUPTURE OF EARDRUM

382.01 ACUTE SUPPURATIVE OTITIS MEDIA WITH SPONTANEOUS RUPTURE OF EARDRUM

382.1 CHRONIC TUBOTYMPANIC SUPPURATIVE OTITIS MEDIA

382.2 CHRONIC ATTICOANTRAL SUPPURATIVE OTITIS MEDIA

382.3 UNSPECIFIED CHRONIC SUPPURATIVE OTITIS MEDIA

382.4 UNSPECIFIED SUPPURATIVE OTITIS MEDIA

382.9 UNSPECIFIED OTITIS MEDIA

383.00 ACUTE MASTOIDITIS WITHOUT COMPLICATIONS

383.01 SUBPERIOSTEAL ABSCESS OF MASTOID

383.02 ACUTE MASTOIDITIS WITH OTHER COMPLICATIONS

383.1 CHRONIC MASTOIDITIS

383.30 POSTMASTOIDECTOMY COMPLICATION UNSPECIFIED

383.31 MUCOSAL CYST OF POSTMASTOIDECTOMY CAVITY

383.32 RECURRENT CHOLESTEATOMA OF POSTMASTOIDECTOMY CAVITY

383.33 GRANULATIONS OF POSTMASTOIDECTOMY CAVITY

385.30 CHOLESTEATOMA UNSPECIFIED

385.31 CHOLESTEATOMA OF ATTIC

385.32 CHOLESTEATOMA OF MIDDLE EAR

385.33 CHOLESTEATOMA OF MIDDLE EAR AND MASTOID

385.35 DIFFUSE CHOLESTEATOSIS OF MIDDLE EAR AND MASTOID

385.82 CHOLESTERIN GRANULOMA OF MIDDLE EAR

385.83 RETAINED FOREIGN BODY OF MIDDLE EAR

385.89 OTHER DISORDERS OF MIDDLE EAR AND MASTOID

385.9 UNSPECIFIED DISORDER OF MIDDLE EAR AND MASTOID

386.19 OTHER PERIPHERAL VERTIGO

386.40 LABYRINTHINE FISTULA UNSPECIFIED

386.41 ROUND WINDOW FISTULA

386.42 OVAL WINDOW FISTULA

386.43 SEMICIRCULAR CANAL FISTULA

386.48 LABYRINTHINE FISTULA OF COMBINED SITES

387.9 OTOSCLEROSIS UNSPECIFIED

388.60 OTORRHEA UNSPECIFIED

388.61 CEREBROSPINAL FLUID OTORRHEA

388.69 OTHER OTORRHEA

388.70 OTALGIA UNSPECIFIED

388.71 OTOGENIC PAIN

388.72 REFERRED OTOGENIC PAIN

389.00 CONDUCTIVE HEARING LOSS UNSPECIFIED

389.03 CONDUCTIVE HEARING LOSS MIDDLE EAR

389.05 CONDUCTIVE HEARING LOSS, UNILATERAL

389.06 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 MIXED HEARING LOSS, UNSPECIFIED

389.21 MIXED HEARING LOSS, UNILATERAL

389.22 MIXED HEARING LOSS, BILATERAL

389.8 OTHER SPECIFIED FORMS OF HEARING LOSS

 

 

Documentation 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.

o 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).

 

 

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.

 

 

Treatment Logic

• 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.

 

 

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.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD MASTOIDECTOMY CAVITY DEBRIDEMENT