# retromolar trigone - removal of foreign body



## maryir (Nov 23, 2011)

Please - any help you can give in coding this one would be much appreciated.

]INDICATIONS FOR PROCEDURE:  The patient is a 5-year-old girl who was             
        undergoing a dental procedure and during the nerve block portion of the             
        procedure, the needle was dislodged and lost in the soft tissues around the             
        retromolar trigone.  The foreign body was confirmed by x-ray and             
        subsequently she was sent to an oral surgeon for operative retrieval.  At             
        an outside institution, they were unable to achieve this, and she was             
        subsequently sent to the otolaryngology clinic for further treatment.  
         She was taken to the OR for concerns        
        of worsening dysphagia, nausea and vomiting.             

        PROCEDURE IN DETAIL:  After informed consent was obtained from the             
        patient's parents, the patient was taken to the operating room and placed             
        supine on the operating room table.  A 4.5 endotracheal tube was placed.             
        After successful induction, the patient was turned 180 degrees and prepped             
        and draped in standard sterile manner.  A McIvor mouth retractor was used             
        to place the patient into suspension on the Mayo stand and a smiley mouth             
        retractor was used to expose the soft tissues of the right retromolar             
        trigone.             

        The prior incision was opened with Bovie electrocautery on cut, and using a             
        Kelly clear to auscultation and percussion, the soft tissues around the             
        retromolar trigone were dissected.  We initially tried to verify the             
        position with the ultrasound.  However, we were unable to identify the             
        needle on ultrasound.  The C-arm was therefore used to verify the position             
        of the needle.             

        The needle appeared to be located medial to the ascending ramus of the             
        mandible imbedded in the soft tissues posterior and superior to the right             
        retromolar trigone.  We therefore dissected in this plane, and on multiple             
        shots with the C-arm, we used a spinal needle to try to localize the             
        foreign body.  However, we were unable to directly visualize the foreign             
        body and the C-arm was incapable of shooting in a lateral plane and was    not             
        able to shoot through the bed.  Therefore, after significant dissection             
        around the retromolar trigone posteriorly and posteriorly towards the             
        pterygoid plates, we decided to abort the procedure after several hours.             
        Surgicel was placed into the wound bed and the incision closed with             
        interrupted 3-0 Vicryl sutures.             

        The patient was turned back to anesthesia, extubated in the operating room             
        and wheeled to the recovery room in stable condition.


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## johnmeyer (Nov 27, 2011)

*Try this....*

76998-26 to charge for the intraoperative ultrasonic guidance, even though they couldn't find the needle with it.

41805-53 for the attempted unsuccessful removal of the needle.


I was thinking that you might be able to code the endotracheal intubation using 31500, but I don't think you can because part of the definition of the code includes "emergency procedure" and I don't feel as though this could be considered an emergency procedure.

Also, since a C-arm was used, you might want to go back and ask the surgeon if it was used radiographically or fluoroscopically so you could code that too.


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## Lujanwj (Nov 28, 2011)

Perhaps 10121-53 because it doesn't quite sound like Dr was in the actual "Structures" but more in the soft tissue mid-ramus.  

As with Pogiest,  I'd also code a -26 on whatever "radio" the Dr did but make sure dr has a separate report with indications and findings.  Didn't happen if there isn't a separate report.


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