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Otolaryngology Coding Alert

Reader Question:

Consider Cholesteatoma Removal Incidental

Published on Wed Oct 31, 2012

Question: Under general anesthesia, an otolaryngologist explores a chronic otitis media patient's middle ear through a canal incision. During the middle-ear exploration, he removes keratinous debris. May I separately report the debris removal?Mississippi SubscriberAnswer: No, you shouldn't bill for the debris removal. The debris removal is from a cholesteatoma, a benign tumor filled with desquamating debris. CPT contains no code for this procedure and considers the removal incidental to the middle-ear exploration. However, you should code for the exploration with 69440 (Middle-ear exploration through postauricular or ear canal incision). Link 69440 to 385.32 (Cholesteatoma of middle ear).
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