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Help!!

  1. #1
    Location
    Madisonville Pennyrile Kentucky Chapter
    Posts
    29
    Default Help!!
    Medical Coding Books
    How would you code this? Please see below:


    PREOPERATIVE DIAGNOSIS: Post mastoidectomy hemorrhage.

    POSTOPERATIVE DIAGNOSIS: Post mastoidectomy hemorrhage.

    PROCEDURE PERFORMED: Control of post mastoidectomy hemorrhage.

    INDICATIONS: This gentleman had a tympanomastoidectomy done apparently
    at Vanderbilt about a week and a half ago. He was doing well until
    today when a door accidentally hit him on the ear and he began to have
    profuse bleeding from the ear canal, that continued for hours. He
    presented to the emergency department, attempts there were
    unsuccessful, and it was opted to bring him to the operating room for
    exploration and control of the hemorrhage.

    DESCRIPTION OF PROCEDURE: Under general endotracheal anesthesia, the
    right ear was draped and prepped in a sterile manner. There was some
    bleeding arising from the external canal and a considerable amount of
    blood clots present. Suction was used under the visualization of the
    operating microscope. The entire tympanomastoid cavity was filled with
    blood and this was suctioned. The bleeding area appeared to be in the
    subcutaneous region essentially at the level of the temporalis muscle
    at the posterior aspect of the incision site. It responded well to
    hemostatic agents specifically Surgicel. Blood loss during the
    procedure was less than 100 mL. Blood loss prior to the procedure
    appeared to be about 700-800 mL. A Glasscock dressing was applied.
    Hemostasis was complete. The patient was uneventfully awakened and
    brought in stable condition to the recovery area.

  2. Default
    No cut was performed. that rules out the incision or excision, 69000-69155.

    My surgery code pick is 69222-RT-78 which is debridement mastoid w/ anesthesia. The -RT should clarify which ear, so the insurance doesn't then have to ask for the op note. The -78 is likely as this ear procedure is within the global of the 1st procedure.


    Diagnosis is likely hematoma of the ear.



    Also, was patient admitted overnight? Was patient discharged the same day? Just curious as that has to do with the 21 or 22 facility code.

    Didn't consider any E&M codes, by the way, just the surgery code.
    Last edited by ENTcoderConnecticut; 09-18-2014 at 10:58 PM.

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