Wendy0715
New
Hello!
Please help with the following surgery. My thoughts are to use 69603 with an unlisted code compared to 69310 for the rambo flap/canal closure revision and then using 69719 for the OSIA replacement which i think would bundle the BAHA abutment removal with that. Thoughts please!!
Before prepping and draping the surgical site, we began by removing the existing BAHA abutment. Using the BAHA screwdriver and counter torque wrench, we loosened the central coupling screw and removed the abutment from the scalp, leaving the osseointegrated implant in place. We then prepped and sterilely draped the surgical site in the usual fashion for ear surgery.
We then proceeded with our revision subtotal petrosectomy. Using a 15-blade scalpel, we made a large C-shaped excision just posterior to the edge of the mastoid cavity (prior incision was retracted into the cavity). After dissecting down to the level of the temporalis muscle and mastoid periosteum, we incised the periosteum on the posterior edge of the mastoid cavity. We then elevated the periosteum into the mastoid cavity, elevating and excising the dense scar filling the cavity. We ultimately reached the middle ear space, encountering a large cholesteatoma occupying the supratubal recess and anterior mesotympanum. The cholesteatoma excised and a sample was send as a specimen for pathologic evaluation.
After fully excising the cholesteatoma, we proceeded to perform a revision petrosectomy. Starting by excising the retracted portion of the EAC/blind pouch closure, which was noted to be scarred to the anterior aspect of the EAC. We revised the EAC closure using the Rambo flap techniques, ensuring we excised any remaining skin medial to the revised closure. The skin of the EAC was closed using 3-0 Vicryl suture. We then revised the petrosectomy cavity, using the surgical drill and coarse diamond bits to confirm the bony limited of the mastoid cavity and to drill away a layer of bone from the epitympanum, anterior ear canal, and anterior mesotympanum to ensure removal of any residual cholesteatoma matrix from the bone. We also revised the facial ridge to optimize our view of the round window and oval window. The sinus tympani, oval window and round window niche were noted to be covered in dense scar. The stapes superstructure was found to be near-completely eroded. Leaving dense scar filling the sinus tympani, we dissected scar off of the oval window and partially away from the round window niche, and confirmed the presence of a round window reflex with gentle palpation of the stapes foot plate.
We then turned our attention to the placement of the Osia. The overgrown skin around the previous BAHA site was carefully excised with an ellipsoid incision using a combination of sharp dissection and electrocautery. The abutment site was then identified and careful elevation in the subperiosteal plane allowed for good exposure of the surrounding bone. A silicone implant was to mark out the anticipated positioning of the Osia device and a subcutaneous pocket was made to the appropriate depth to allow for tunneling the device. The device was then opened and placed into the prepared pocket. The fixation screw was placed over the countersink from the previous BAHA site and tightened. The tightness was confirmed with the appropriate torque wrench.
Please help with the following surgery. My thoughts are to use 69603 with an unlisted code compared to 69310 for the rambo flap/canal closure revision and then using 69719 for the OSIA replacement which i think would bundle the BAHA abutment removal with that. Thoughts please!!
Before prepping and draping the surgical site, we began by removing the existing BAHA abutment. Using the BAHA screwdriver and counter torque wrench, we loosened the central coupling screw and removed the abutment from the scalp, leaving the osseointegrated implant in place. We then prepped and sterilely draped the surgical site in the usual fashion for ear surgery.
We then proceeded with our revision subtotal petrosectomy. Using a 15-blade scalpel, we made a large C-shaped excision just posterior to the edge of the mastoid cavity (prior incision was retracted into the cavity). After dissecting down to the level of the temporalis muscle and mastoid periosteum, we incised the periosteum on the posterior edge of the mastoid cavity. We then elevated the periosteum into the mastoid cavity, elevating and excising the dense scar filling the cavity. We ultimately reached the middle ear space, encountering a large cholesteatoma occupying the supratubal recess and anterior mesotympanum. The cholesteatoma excised and a sample was send as a specimen for pathologic evaluation.
After fully excising the cholesteatoma, we proceeded to perform a revision petrosectomy. Starting by excising the retracted portion of the EAC/blind pouch closure, which was noted to be scarred to the anterior aspect of the EAC. We revised the EAC closure using the Rambo flap techniques, ensuring we excised any remaining skin medial to the revised closure. The skin of the EAC was closed using 3-0 Vicryl suture. We then revised the petrosectomy cavity, using the surgical drill and coarse diamond bits to confirm the bony limited of the mastoid cavity and to drill away a layer of bone from the epitympanum, anterior ear canal, and anterior mesotympanum to ensure removal of any residual cholesteatoma matrix from the bone. We also revised the facial ridge to optimize our view of the round window and oval window. The sinus tympani, oval window and round window niche were noted to be covered in dense scar. The stapes superstructure was found to be near-completely eroded. Leaving dense scar filling the sinus tympani, we dissected scar off of the oval window and partially away from the round window niche, and confirmed the presence of a round window reflex with gentle palpation of the stapes foot plate.
We then turned our attention to the placement of the Osia. The overgrown skin around the previous BAHA site was carefully excised with an ellipsoid incision using a combination of sharp dissection and electrocautery. The abutment site was then identified and careful elevation in the subperiosteal plane allowed for good exposure of the surrounding bone. A silicone implant was to mark out the anticipated positioning of the Osia device and a subcutaneous pocket was made to the appropriate depth to allow for tunneling the device. The device was then opened and placed into the prepared pocket. The fixation screw was placed over the countersink from the previous BAHA site and tightened. The tightness was confirmed with the appropriate torque wrench.