Transtympanic therapeutic injections are a common procedure performed by otolaryngologists for various otologic conditions, such as sudden sensorineural hearing loss and severe cases of vertigo when observed in some patients with Meniere’s disease. A patient may use any variety of medications, and the patient may need a single injection, or a series of injections performed over multiple days.
For each separate encounter/instillation (separate ear, separate day), report CPT code 69801, Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal (Do not report 69801 more than once per day) (Do not report 69801 in conjunction with 69420, 69421, 69433, 69436 when performed on the same ear)
Since code revision in 2011, 69801 now has a zero-day global period and the tube placement is included in the code. The instilled medication is reported separately using a HCPCS code.
As always, ensure your documentation fully supports your treatment rationale and coincides with the CPT codes submitted in the claim. Be prepared to send clinical notes if the claims examiner needs further information to process the claim.
Reviewed October 2023