AN2114
Guru
I wanted to get an opinion on this op report. I know there is no code for ossicular chain reconstruction or excision of canal cholesteatoma and the closest code would be 69632. The doctor did not repair the tympanic membrane but because of the reconstruction and removal of cholesteatoma, can I still use 69632 or should I do 69632-52?
Procedures: Left middle ear exploration with ossicular chain reconstruction, excision of canal cholesteatoma.
Patient was taken to surgery anesthetized under general anesthesia properly prepped and draped. Attention was first drawn to the left ear with the operative microscope. The ear was brought into view and the external canal and tympanic membrane was focused and upon there was noted to be a small canal cholesteatoma, and a well healed tympanic membrane with no evidence of perforation. The bony annular rim was infiltrated with a solution of 1% Xylocaine w/1:100k epinephrine. Attention was then drawn to the middle ear, a tympanic membrane flap was elevated and the middle ear was entered carefully taking care to not cause any perforation in the tympanic membrane. There was silastic sheeting that was encountered in the middle ear cleft, this was removed to reveal healthy middle ear mucosa without any evidence of residual cholesteatoma. The stapes footplate was then identified and a Dorhaufer prosthesis was trimmed to 3 mm in size and placed over the stapes footplate and manipulated into a good position. The tympanomeatal flap was then laid back down and the prosthesis was found to be in good position not causing tenting of the TM. The middle ear space was then packed with ciprodex soaked gelfoam. Next attention was turned to the canal cholesteatoma, this was removed using suction and instrumentation. Next the tympanomeatal flap was laid back making sure the edges were unfurled and in good position. The ear canal was then packed with ciprodex soaked gelfoam and bacitracin ointment. A glasscock dressing was placed and he was then turned back to anesthesia where he was extubated and taken to recovery in satisfactory condition.
Procedures: Left middle ear exploration with ossicular chain reconstruction, excision of canal cholesteatoma.
Patient was taken to surgery anesthetized under general anesthesia properly prepped and draped. Attention was first drawn to the left ear with the operative microscope. The ear was brought into view and the external canal and tympanic membrane was focused and upon there was noted to be a small canal cholesteatoma, and a well healed tympanic membrane with no evidence of perforation. The bony annular rim was infiltrated with a solution of 1% Xylocaine w/1:100k epinephrine. Attention was then drawn to the middle ear, a tympanic membrane flap was elevated and the middle ear was entered carefully taking care to not cause any perforation in the tympanic membrane. There was silastic sheeting that was encountered in the middle ear cleft, this was removed to reveal healthy middle ear mucosa without any evidence of residual cholesteatoma. The stapes footplate was then identified and a Dorhaufer prosthesis was trimmed to 3 mm in size and placed over the stapes footplate and manipulated into a good position. The tympanomeatal flap was then laid back down and the prosthesis was found to be in good position not causing tenting of the TM. The middle ear space was then packed with ciprodex soaked gelfoam. Next attention was turned to the canal cholesteatoma, this was removed using suction and instrumentation. Next the tympanomeatal flap was laid back making sure the edges were unfurled and in good position. The ear canal was then packed with ciprodex soaked gelfoam and bacitracin ointment. A glasscock dressing was placed and he was then turned back to anesthesia where he was extubated and taken to recovery in satisfactory condition.