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Mass removal?

  1. #1
    Default Mass removal?
    Medical Coding Books
    I'm not sure what CPT code to use for this dictation (see below). The physician used 69450 but that sounds like it requires cutting and flapping the ear drum. Any suggestions?
    Thanks in advance,

    S: The patient is seen in follow-up regarding whitish mass on the left eardrum.

    Audiometric testing: Normal hearing in both ears at all frequencies. Tympanometry is A-type curve on both sides.

    CT of temporal bone: The whitish mass is strictly related to the left eardrum, with no extension into the middle ear space.

    Left ear canal was injected with 1% Xylocaine with 1:100,000 epinephrine. The mass was excised from the surface of the drum. It did not extend into the middle ear space. The drum is left intact. Bleeding is controlled with touching of silver nitrate to the bleeding point on the drum.

    A&P: Apparent squamous cyst on the left eardrum. This was excised. I will see her in 1 month.

  2. #2
    Default Ear Drum
    I'm inclined to use the 69450. The Encoder also suggest this CPT and after reading the descriptions of the 694xx series I think the 69450 is the closest to the procedure performed.

    Hope this help, any other feedback is always welcome!!

  3. #3
    I coded a similar procedure to this just last week. Take a look at 69145 since your physician dictates that the lesion did not extend into the middle ear space. The description for 69145 from Custom Coder reads: The physician removes a lesion from the soft tissues of the auditory canal outside of the ear drum. Hope this helps!

  4. #4
    Thank you to both of you for your responses. I'll definitely check out that other code. It's so nice to have these forums available. It makes me feel much less alone out there in the real world!

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