abbyh21
New
I've searched high and low for this:
Patient comes in to the OR with a documentation of "Foreign body bilateral ears".
In the left ear, wax is removed with a curette under a microscope.
In the right ear, granulation tissue and polyp or cauterized off the membrane and submitted for permanent examination.
My original code was 69205-RT, I thought I read somewhere that this covered the removal of granulation tissue. I did not code the removal cerumen because no where does the surgeon specify that the wax is impacted, but the coder for the doctor reached out to me asking if we could code 69210-LT and 69540-RT. I am willing to change to 69540 for the removal of the polyp , but I am having a hard time finding any info on the cerumen removal of the left ear.
Here is the OP report:
Patient comes in to the OR with a documentation of "Foreign body bilateral ears".
In the left ear, wax is removed with a curette under a microscope.
In the right ear, granulation tissue and polyp or cauterized off the membrane and submitted for permanent examination.
My original code was 69205-RT, I thought I read somewhere that this covered the removal of granulation tissue. I did not code the removal cerumen because no where does the surgeon specify that the wax is impacted, but the coder for the doctor reached out to me asking if we could code 69210-LT and 69540-RT. I am willing to change to 69540 for the removal of the polyp , but I am having a hard time finding any info on the cerumen removal of the left ear.
Here is the OP report:
Thanks in advance for the help.Post op dx: FB in both ears
Procedure: Debridement of both ears
Procedure in detail:
The patient was taken to the OR and after induction of general anesthesia, was prepped and draped in a sterile manner. Entire left ear canal was filled with wax and this was removed with a curette with envisioned with a microscope. The tympanic membrane was found to be mobile. Antibiotic drops were instilled in the ear. Attention was turned to the opposite ear where similarly wax was removed from the external canal. He had a large granulation polyp on the external surface of the tympanic membrane. This was removed with suction cautery. No further bleeding was encountered. Antibiotic drops were instilled in the ear and the procedure was terminated. The patient was allowed to awaken and was taken to the recovery room in stable condition.