Wiki Help with Coding - How would you code the following?

jrs3181

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How would you code the following?

Preoperative Diagnoses: Chronic Adenoiditis and adenoid hypertrophy and chronic otitis media with effusion.

Procedure: Adenoidectomy and bilateral tube removal with culture on the left and paper patch on the right.

Description: The patient was prepped and draped in the usual manner, under a satisfactory general endotracheal anesthesia. A Crowe-Davis mouth gag was inserted after inspecting for loose teeth. A 3+ enlarged infected adenoid pad was encountered and removed with Coblation technique. Hemostatis was obtained with suction cautery and Coblation. Attention was then directed to the right ear. The previously placed T-tube was removed and the perforation freshened with silver nitrate and a paper patch applied. On the opposite side, there was pus in the ear. I removed the tube and sent it for culture and did not apply a patch. At this point, the entire procedure was terminated. The estimated blood loss was about 15cc. The patient tolerated the procedure well and went to the recovery room in a good condition.

I have:

J35.02
J35.2
H66.3X2

42831
69424 50
 
Happy to help!

Your diagnosis codes look good, except you need to include the diagnosis for the right ear that necessitated the paper patch tympanoplasty? (Based on the documentation from the op note, it is a central tympanic membrane perforation, H72.01)

For procedure codes:

42831
69610-RT (ear tube removal is bundled into a paper patch tympanoplasty)
69424-LT

Hope that helps!

Jennifer M. Connell, BA, CPC, CPPM, CPCO, CENTC
 
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