l1ttle_0ne
Guru
I'm billing for a 69631 and they did a tragal cartilage graft as well as a temporalis fascia graft. I was told I could only bill for the cartilage graft (21235) and not the temporalis fascia graft (15769). But when I research it, it sounds like I can bill for both? There are no bundling edits, but can I get another opinion? The CPT Assistant states " The August 2008 CPT Assistant discussed the repair of a tympanic membrane perforation, wherein a graft is harvested from either the temporalis fascia or other locations (ie, vein, periosteum, or conchal cartilage perichondrium). Occasionally, a graft is used from material other than autogenous tissue. If the temporalis fascia graft is harvested through a separate donor incision, the harvesting should be reported separately from the tympanoplasty.
The August 2008 coding guidance supersedes the March 2007 CPT Assistant instruction, as it agrees with the general CPT convention that graft harvest is reported separately under these conditions: (1) when obtained through a different incision; and (2) when the descriptor language does not specify graft harvest as integral to a service. "
I'm also questioning if the temporalis fascia graft would be billed as 15769 or 15733? I have someone saying 15733 but that says it's a pedicle flap, and this sound like it was completely excised.
Any help would be great! Here is the op note-
PROCEDURE:
1. Left revision tympanoplasty.
2. Left tragal cartilage graft (1 cm x 1 cm).
3. Right temporalis fascia graft (1 cm x 1 cm).
DESCRIPTION OF PROCEDURE: After the patient was identified in the preoperative holding area, was taken
back to the operating room, prepped and draped in standard supine position for the above-outlined surgery.
After induction of a general anesthetic and endotracheal intubation, a surgical time-out was performed. Both
ears were draped sterilely by the nursing staff. The microscope was sterilely prepped and draped.
Preoperatively, after intubation, the right postauricular incisional area was injected with 1% lidocaine with
1:100,000 epinephrine solution, and similarly, prior to microscope being draped, the left external auditory canal
was injected with 2 mL in the bony cartilaginous junction around the surfaces of the clock at 12 o'clock, 9
o'clock, 6 o'clock, and 3 o'clock.
After 8 minutes of action of this hemostatic agent, the right postauricular incision was developed, measuring
approximately 4 cm in vertical height, just posterior to the auricle, into the hairline. Bovie electrocautery
dissected down to the temporalis muscle. The temporalis fascia was identified. Curved iris scissors help
develop a subcutaneous plane and with Senn retractors exposing the temporalis fascia easily. A 15 blade was
then utilized to incise a 1 cm x 1 cm temporalis fascia graft, and this was pressed and dried through the
remaining aspects of the case. Bovie electrocautery developed a hemostatic field, and 4-0 horizontal mattress
sutures within the dermis helped to close the postauricular incision, and then, next, 4-0 running locking nylon
suture in the cutaneous plane was used to close the incision.
Next, the attention was drawn to the left ear. The tragal graft was harvested. A small, 5 mm incision was
developed on the lateral surface of the tragal cartilage within the ear canal. Curved iris scissors developed a
subcutaneous plane both superiorly and inferiorly to the tragal cartilage, preserving the perichondrium.
Roughly 7 mm x 7 mm cartilage graft was obtained, again preserving the perichondrium. Bovie electrocautery
created a hemostatic field, and 4-0 running nylon suture was used to close the tragal incision.
Next, under binocular microscope, the left external auditory canal was examined using 4.0 ear speculum. The
anterior perforation was seen, measuring roughly 15% of the diameter of the tympanic membrane. A sharp
curved pick was utilized to roughen the edges of the anterior perforation and Cup forceps was used to remove
the excess skin around the peripheral margin, creating approximately a 20% tympanic membrane perforation.
Next, a sickle blade was used to incise at 6 o'clock and at 12 o'clock in the external auditory canal, cutting
down toward the anulus and up to the bony cartilaginous junction. A round knife was then used to connect the
2 incisions, and a tympanomeatal flap was developed. Next, Gelfoam was placed within the middle ear space.
The tragal cartilage graft was placed on top of this incision. Next, temporalis fascia graft was gently applied
over this graft, and the tympanomeatal flap was retracted in its natural anatomical position.
Gelfoam was next placed within the external auditory canal with occasional Floxin saturation of these Gelfoam
pledgets. Mupirocin ointment was squirted into the ear canal with an Angiocath and a 3 mL syringe. Cotton
ball was used to secure this in place. A Glasscock dressing was placed in the right ear for compressive
hemostasis, and a cotton ball was secured in the left external auditory canal with a Band-Aid. The patient was
then gradually woken from his general anesthetic, extubated, and transferred to the recovery room in excellent
condition.
The August 2008 coding guidance supersedes the March 2007 CPT Assistant instruction, as it agrees with the general CPT convention that graft harvest is reported separately under these conditions: (1) when obtained through a different incision; and (2) when the descriptor language does not specify graft harvest as integral to a service. "
I'm also questioning if the temporalis fascia graft would be billed as 15769 or 15733? I have someone saying 15733 but that says it's a pedicle flap, and this sound like it was completely excised.
Any help would be great! Here is the op note-
PROCEDURE:
1. Left revision tympanoplasty.
2. Left tragal cartilage graft (1 cm x 1 cm).
3. Right temporalis fascia graft (1 cm x 1 cm).
DESCRIPTION OF PROCEDURE: After the patient was identified in the preoperative holding area, was taken
back to the operating room, prepped and draped in standard supine position for the above-outlined surgery.
After induction of a general anesthetic and endotracheal intubation, a surgical time-out was performed. Both
ears were draped sterilely by the nursing staff. The microscope was sterilely prepped and draped.
Preoperatively, after intubation, the right postauricular incisional area was injected with 1% lidocaine with
1:100,000 epinephrine solution, and similarly, prior to microscope being draped, the left external auditory canal
was injected with 2 mL in the bony cartilaginous junction around the surfaces of the clock at 12 o'clock, 9
o'clock, 6 o'clock, and 3 o'clock.
After 8 minutes of action of this hemostatic agent, the right postauricular incision was developed, measuring
approximately 4 cm in vertical height, just posterior to the auricle, into the hairline. Bovie electrocautery
dissected down to the temporalis muscle. The temporalis fascia was identified. Curved iris scissors help
develop a subcutaneous plane and with Senn retractors exposing the temporalis fascia easily. A 15 blade was
then utilized to incise a 1 cm x 1 cm temporalis fascia graft, and this was pressed and dried through the
remaining aspects of the case. Bovie electrocautery developed a hemostatic field, and 4-0 horizontal mattress
sutures within the dermis helped to close the postauricular incision, and then, next, 4-0 running locking nylon
suture in the cutaneous plane was used to close the incision.
Next, the attention was drawn to the left ear. The tragal graft was harvested. A small, 5 mm incision was
developed on the lateral surface of the tragal cartilage within the ear canal. Curved iris scissors developed a
subcutaneous plane both superiorly and inferiorly to the tragal cartilage, preserving the perichondrium.
Roughly 7 mm x 7 mm cartilage graft was obtained, again preserving the perichondrium. Bovie electrocautery
created a hemostatic field, and 4-0 running nylon suture was used to close the tragal incision.
Next, under binocular microscope, the left external auditory canal was examined using 4.0 ear speculum. The
anterior perforation was seen, measuring roughly 15% of the diameter of the tympanic membrane. A sharp
curved pick was utilized to roughen the edges of the anterior perforation and Cup forceps was used to remove
the excess skin around the peripheral margin, creating approximately a 20% tympanic membrane perforation.
Next, a sickle blade was used to incise at 6 o'clock and at 12 o'clock in the external auditory canal, cutting
down toward the anulus and up to the bony cartilaginous junction. A round knife was then used to connect the
2 incisions, and a tympanomeatal flap was developed. Next, Gelfoam was placed within the middle ear space.
The tragal cartilage graft was placed on top of this incision. Next, temporalis fascia graft was gently applied
over this graft, and the tympanomeatal flap was retracted in its natural anatomical position.
Gelfoam was next placed within the external auditory canal with occasional Floxin saturation of these Gelfoam
pledgets. Mupirocin ointment was squirted into the ear canal with an Angiocath and a 3 mL syringe. Cotton
ball was used to secure this in place. A Glasscock dressing was placed in the right ear for compressive
hemostasis, and a cotton ball was secured in the left external auditory canal with a Band-Aid. The patient was
then gradually woken from his general anesthetic, extubated, and transferred to the recovery room in excellent
condition.
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