Mastoidectomy with temporalis fascia repair

letwalls

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Please help me with this op report.


Came up with 69641.

Operative report:
A decision was made to proceed first with the mastoidectomy. Post auricular incision was made and carried down through the perichondrium and through to the soft tissues, elevated anteriorly and posteriorly, exposing the mastoid cortex. A standard triangular incision was made and simple mastoidectomy accomplished, exposing the antrum. In the roof of the antrum, small clump of granlulations were seen that were carefully teased off of exposed dura. The area of dehiscence measured probably 5x8mm. It was decided to repair this with temporalis fascia and muscle plug. The incision behind the ear was extended up slightly over the temporalis muscle and a cirlce of fascia with a thin layer of muscle attached was removed. This was laid muscle-down against the dural dehiscence, after being certain the CSF leak was coming from that area. Biopsies of the granulations had shown no evidence of neoplastic process. This dural patch on the roof of the antrum was then reinforced with Gelfoam packing to hold the graft in place and postauricular incision closed.
 
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jackjones62

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Mastoidectomy Re: CSF Leak

CPT 69670 would be correct, Mastoid Obliteration (separate proc.); this procedure specifically addresses CSF leak. CPT 69641 would not appropriate.

Also, the op note did not mention if patient had previous mastoid surgery and I am assuming this procedure was the only procedure done during this case.

JB
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I have a similar issue with coding as this is the first time I have coded for this surgery . My op note reads****


1. canal wall down tympanomastoidectomy with repair of temporal bone defect and CSF leak .

CPT 69643

can you help with the CPT for the CSF Leak (69667, 69670,or 61618) :confused:

thank you for any help you can give

*******first time I have asked a question *******

MHS
 
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