codemeister
Contributor
I wanted to get feedback on the appropriate CPT code(s) based on just the following key information.
Two of the items listed in the TITLE OF OPERATION are:
1) Left radical canal wall down mastoidectomy
2) Palva rotation flap
Three interesting sentences noted in the body of the report:
1) "There was a small area of dehiscence that was noted and when this was opened up with the use of a curet, it became evident that there was further cholesteatoma matrix extending up to the level of the dura."
2) "From our view there was cholesteatoma matrix expanding along the middle cranial fossa in all directions."
3) "To our best extent, a cup forceps as well as a ball probe was used to peel the cholesteatoma matrix off of the dura itself."
Is this enough info to come up with a code ... or two or three?
Two of the items listed in the TITLE OF OPERATION are:
1) Left radical canal wall down mastoidectomy
2) Palva rotation flap
Three interesting sentences noted in the body of the report:
1) "There was a small area of dehiscence that was noted and when this was opened up with the use of a curet, it became evident that there was further cholesteatoma matrix extending up to the level of the dura."
2) "From our view there was cholesteatoma matrix expanding along the middle cranial fossa in all directions."
3) "To our best extent, a cup forceps as well as a ball probe was used to peel the cholesteatoma matrix off of the dura itself."
Is this enough info to come up with a code ... or two or three?