Ear lesion excision / flap reconstruction / abscess drainage

rgeib

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(I've posted this to 3 forums to get input from a dermatology, plastic surgery and ENT perspective)

So I have the following procedure description during an office visit:

"HPI:
Patient presents for eval for left ear lesion. He has a hx of left auricular abscess that was previously I&D'd and placed on extended course of Abx. He secondarily developed a cauliflower ear deformity. His reports an 80% improvement to his abscess with only mild residual drainge. He also has a 5mm skin lesion at the root of the helix on the same ear that was biopsied by previous ENT and found + for SCCA. The lesion appears to be separate from the abscess. + smoker, currently on levaquin and has approx 1 week left. He denies any pain in the ear today. He has a longstanding hearing loss in that ear was well and wears a HA in the right ear.

Plan:
biospy + SCCA excised on the superior helix. The second portion of the procedure was extensive and included complete de-epithelization of a subcutaneous fistulous tract and pocket that extended the entire length of the concha likely formed secondary to his previous infection/abscess and led to his persistent foul smelling drainage. The procedure was initially scheduled for 1 hour but took 2 hours to complete because of the unforseen extensive nature of the fistulous track and pocket.
I reviewed his post procedure instructions and precautions in detail and questions answered. He will follow up tomorrow for wound check.

Full procedure note:
After written consent was obtained from the patient, the skin overlying the 6mm lesion at the superior helix was cleaned with alcohol and injected with 0.5ml 1% lidocaine with 1:100,000 epinepherine. The neck was then draped with a sterile drape. The left ear was then prepped with betadine. 3mm margins around the skin lesion on the superior helix were then outlined with a marking pen. A scalpel was then used to make an elliptical incision around the lesion with a defect size of 1.4 x 2cm. Scissors were then used to dissect the lesion from its surrouding tissues until it was removed in its entirety. The specimen was marked long stitch as anterior and short stitch as superior.

Attention was then focused on the adjacent draining fistula at the helical root. The tract was probed and explored and found to be an extensive subcutaneous pocket with foul smelling dishwater like drainage. The ear was then incised along the scaphoid fossa elevating a skin flap over the outer ear over the superior portion of helix and concha cymba. Complete epithelialization of the subcutaneous tissues was extensive and present in the pouch. Foul smelling clear drainage was present. The entire area was carefully depithelialized. The fistulas tract was depithelialized and closed. The wound was irrigated copiously with half strength peroxide and then closed using 5-0 prolene sutures. The left ear was then dressed with dental bolsters soaked in iodine and xeroform gauze sutured to the ear with 2-0 prolene sutures. The patient tolerated the procedure well."

At first, I was thinking of going with 11602 & 12051 for the lesion excision + closure & an adjacent tissue transfer code for the mentioned cleaning of the abscess. I know that malignant lesion excision is included in tissue transfer on the same location, but the physician is addressing 2 separate issues here (cancerous lesion and infected abscess). So I'm not sure which way to go. Also, the provider is generating a service order for 69005 (Drainage of external ear abscess), so should this be considered as well since no measurements are given for the abscess pocket? Any advice here would be appreciated. Thanks.
 
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