# 69642 or 69637



## ASC CODER

Transcanal injections were then performed, as well as a postauricular sulcus injection for possible graft harvest. Her ear was then prepped and draped in sterile fashion with Betadine solution. Using the operative microscope, a tympanomeatal flap was then raised using a curved Beaver blade, subsequently followed by a weapon elevator. The middle ear mucosa was incised with a Rosen needle and then the annulus elevator was then used to elevate the rest of the tympanomeatal flap. There was some cartilage that was impregnated into the eardrum. Underneath this was a titanium head that was incorporated into the cartilage. Sitting on top of the capitulum of the stapes was a shaft, however, the titanium head was separate from the shaft, with no communication or articulation. Therefore, the titanium head was removed. The shaft was removed from the capitulum. The middle ear mucosa and space was evaluated. It was healthy. The stapes capitulum was palpated gently and felt to be intact, with an intact superstructure. Manubrium of the malleus was palpated with mobility noted as well. Therefore, a Dornhoffer middle ear PORP with adjustable links was chosen for reconstruction. Sizes were used to identify the appropriate length, which was 2.5 mm. It was then cut to the appropriate size. 

A postauricular incision was then performed for harvesting a fascial graft. A small fascial graft was harvested, overriding the temporalis muscle. This was mainly a scar and fatty tissue and loose areolar tissue, as the temporalis fascia was not present. This was placed on a press and then dried on a back table. 

The fascial graft was then laid in an underlay technique re-enforcing the posterior aspect of the eardrum that had been previously elevated and advanced to the level of the manubrium of the malleus. The Dornhoffer implant was then placed in the lateral canal, positioned on top of the capitulum of the stapes, and then gently swung its hydroxyapatite head until it was in good approximation with the manubrium of the malleus with the knots positioned nicely on the manubrium. The posterior middle ear space was then filled with some Gelfoam to help support the graft. The graft was then brought back into its normal position on top of the medial canal, and then two small further pieces of Gelfoam were applied to the incision site, followed by subsequent placement of antibiotic ointment.

The postauricular incision was then closed
Doc wants 69642 but I see 69637

am I missing something?


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## ASC CODER

Can you use the 69642 even though it is a synthetic porp and the code discription for 69642 says BONE??


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## Candice_Fenildo

Well you have me stumped there. 69637 would be the most likely code. but i am concerned about the "synthetic" prosthesis. The Dornhoffer implant site and it is clearly titanium. that is hardly synthetic. 
I am gonna dig in on this one..
I love a good challenge


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## ASC CODER

*Your opinion*

with further research this is what I found from Codecorrect.  what is your take??





There are a couple of dura repair codes: 63707 Repair of dural/cerebrospinal fluid leak, not requiring laminectomy 63709 Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy 63710 Dural graft, spinal Here are some articles that you may want to read: http://www.emedicine.com/ent/topic215.htm http://www.telemedical.com/Teleaudiology/diseases2.html http://www.siumed.edu/surgery/otol/residency.htm Otolaryngology Coder's Pink Sheet Effective Date 10/01/2003 Publish Date October 2003 Subject Tympanic memberane repair "Match op note, CPT terminology for correct tympanoplasty code A tympanic repair can be as simple as a paper patch or much more complicated (eg, tympanoplasty with mastoidectomy and OSSICULAR CHAIN reconstruction). To cover this wide range of possibilities, CPT includes 14 codes for tympanic repair. To select the correct one, you need to know how these services – many of which are extremely complex – differ from each other, and your otolaryngologist has to document these services keeping in mind the terminology used by CPT. For example, if the otolaryngologist notes that a tympanoplasty was performed involving drilling in the mastoid, you have to find out whether sufficient mastoid tissue was removed for a mastoidectomy; otherwise, you'll have to report a tympanostomy with mastoidotomy instead. “Think of tympanic membrane repair codes as belonging to one of five groups that increase in complexity,” says Lee Eisenberg, MD, otolaryngologist, Englewood , N.J. The first Tympanic repair codes Choose from one of 14 tympanic repair codes: Code Fee OSSICULAR CHAIN Prosthesis Procedure type 69610 $330 N/a N/a Tympanic membrane only 69620 $484 N/a N/a Tympanic membrane only 69631 $726 No No Tympanoplasty, no mastoidectomy 69632 $927 Yes No Tympanoplasty no mastoidectomy 69633 $888 Yes Yes Tympanoplasty no mastoidectomy 69635 $917 No No Tympanoplasty, mastoidotomy or antrotomy 69636 $1,077 No Yes Tympanoplasty, mastoidotomy or antrotomy 69637 $1,070 Yes Yes Tympanoplasty, mastoidotomy or antrotomy 69641 $900 No With and without Tympanoplasty, mastoidectomy 69642 $1,173 Yes With and without Tympanoplasty, mastoidectomy 69643 $1,081 No With and without Tympanoplasty, mastoidectomy 69644 $1,180 Yes With and without Tympanoplasty, mastoidectomy 69645 $1,144 No With and without “ “ Radical or complete 69646 $1,242 Yes With and without “ “ Radical or complete group – 69610 (paper patch) and 69620 (myringoplasty involving drum head only) – are the simplest, and don't involve tympanoplasty per se. The next group of codes – 69631 to 69633 – describes tympanoplasties without mastoidectomies. Then comes 69635 to 69637, which include antrotomies or mastoidotomies, where some mastoid tissue is removed. The next set of codes, 69641 to 69644, involve full-blown mastoidectomies, and the final group, 69645 and 69646, are for radical or complete tympanoplasties, also with full mastoidectomies. The individual codes in all of the groups differ based on whether OSSICULAR CHAIN reconstruction was performed or whether heterograft was used. Another factor – the presence of an intact or reconstructed wall – influences code selection for the fourth group (69641-69645), but these codes don't distinguish between homograft and heterograft, Eisenberg says. So, for example, if reconstruction were performed without OSSICULAR CHAIN reconstruction, you'd bill 69641 regardless of whether a prosthesis was implanted or not. Likewise, if the tympanoplasty with mastoidectomy did not involve OSSICULAR CHAIN reconstruction and there was no intact or reconstructed wall, the correct code would be 69642, whether there was a prosthesis or not. However, doing so isn't always easy because the otolaryngologist's dictation may not be specific enough or may not use the same terminology as CPT. In addition, many of the codes are out of date and don't necessarily describe accurately what the otolaryngologist did, Eisenberg says, pointing out that, for example, “there isn't a code for a second stage procedure.” Still, the codes are likely to be around for a while, as nobody wants to see them go, despite their inadequacies. The reason? “Nobody wants these relatively well paid codes to go through the RUC [Relative Value Update Committee] process,” says Randa Blackwell, reimbursement manager, Maryland ENT, Baltimore . “The procedure DESCRIPTIONs, as they currently stand, are antiquated, which can be a big problem because they don't correspond to how otolaryngologists actually do these procedures. But going through the RUC process can be very expensive, and they'd have to redo every code.” Final note: All the codes from 69631 onward include canaloplasty and middle ear surgery. Codes not involving mastoidectomies (ie, 69631 to 69637) also include atticotomy, whereas those involving mastoidectomies (69641 to 69646) also include tympanic membrane repair, when performed. These services should never be billed separately when tympanoplasty is performed."


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## nsteinhauser

Interesting.  I'd pick 69637, even if it is titanium.  I read 69642 to mean the reconstruction was done with the pt's own bone or "a cadaver ossicle" as the description says - and I can't see in the dictation that the surgeon did that.  

Just another opinion weighing in .....


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## ASC CODER

Ok I see your point but what about the approach?  a tympanomeatal flap  He did not go in by postauricule   so doesn't 69637's description say the approach is through a postauricular incision and removes the mastoid cortex (outer bone) that is were I am confused??


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