(A 45-year-old patient has a history of chronic otitis media in the left ear. The otolaryngologist performs atympanoplastyand doesnot remove the mastoidto repair the patient’s perforated tympanic membrane.What CPT® and ICD-10-CM codes are reported?)
A tympanoplasty repairs aperforated tympanic membrane. The key phrase “doesnotremove the mastoid” means this istympanoplasty without mastoidectomy, which is correctly represented by69631in the answer set. Codes that include mastoid work (or represent different tympanoplasty variants) are incorrect because the documentation explicitly states the mastoid was not removed. Diagnosis coding should reflect both thechronic otitis mediaand theperforation. In the options,H66.92represents otitis media (as offered) andH72.92represents perforation of the tympanic membrane (as offered). Although the clinical story specifies the left ear, the provided diagnosis options do not include laterality; on CPC-style questions, you choose the best match among the answer choices. Therefore, the correct combination within this question’s choices is69631 with H66.92 and H72.92, matching tympanoplasty without mastoidectomy plus the documented conditions.
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