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Treatment of canal stenosis

  1. #1
    Kansas City, MO
    Default Treatment of canal stenosis
    Medical Coding Books
    Ok all you ENT coders...a biller brought this to me, and I'm not sure what to do.

    Pt has canal stenosis, ear ends in a blind sac.

    Dr coded a 69310.
    Here is her note:

    Using 1% Xylocaine with 1:100,000 epinephrine, the area is anesthetized, An incision is made both vertically and horizontially across the area of stenosis. There is primarily granulation tissue that is deep to this. This is gradually opened until I reach the eardrum, which appears normal. A silver nitrate stick is used to cauterize the granulation tissue, and a pope wick is placed just lateral to the drum.

    Is this sufficient for a 69310? My CDR says this "reconstruction" usually includes some sort of graft and then some packing. I don't see any other codes that are more appropriate, but I'm not sure the 69310 is right either.

    Thanks for any feedback.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  2. Default
    I think CPT 69310 would be appropriate with modifer 52; according to my coding companion a post-auricular incision is made, some drilling of the bony canal maybe done and it is usually repaired with thin skin grafts; this was a limited meatoplasty of the ear canal, the RVU is significant and not reflective of what this ENT did, but, the end result is the same, to open and re-establish the ear canal, it was just performed at a reduced level.

    Hope this helps,

    CT ENT

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