# For the skin experts



## elenax (Mar 31, 2009)

*The Doc coded  with a 14300 I kind of disagree on that...I was told by another source to use a 69399...I would love to hear more feed back on this one!*

*PREOPERATIVE DIAGNOSIS:* Large, acquired defect, left ear, secondary to Mohs surgery and failed reconstruction times two. 
*POSTOPERATIVE DIAGNOSIS:*                        Same. 

*PROCEDURE:* 

Excision and debridement of necrotic tissue, left ear, with primary bilateral chondrocutaneous flap reconstruction. 
Wedge resection of conchal cartilage and skin. 
 
*CLINICAL HISTORY:* This 70-year-old male previously underwent Mohs surgery on the left ear for basal cell carcinoma. Apparently, the dermatologist performed a local flap, which failed, and then a skin graft, which also failed. The patient was referred. At the time of referral, he had a large defect measuring 25x30 mm, involving both the anterior ear from the scapha triangular fossa across the helical rim, and onto the posterior pinna surface. 

*OPERATIVE PROCEDURE & FINDINGS:* After satisfactory LMA, the patient's ear was prepped with Technicare and draped in a sterile fashion. A periauricular block was accomplished, and some local infiltration into the skin edges. 

The wound was débrided of necrotic tissue, and unfortunately, a large portion of the helical rim cartilage and scapha cartilage was absent. Following debridement, the defect measured approximately 20 mm anterior surface, and 20 mm on the posterior surface, with approximately 20 mm of helical rim and cartilage missing. It was elected to perform a wedge resection with reconstruction of the superior and inferior portions of the ear. Accordingly, an incision was carried into the concha floor and across the antihelical folding cartilage. Following wedge resection of the remaining areas of the defect, the skin was undermined posteriorly and anteriorly for several millimeters beyond the cartilage edge. The cartilage was then reconstructed with figure-of-eight 5-0 Maxon sutures, carefully aligning the helical rim area. Because of the bulge at the antihelical fold, because of the discrepancies in the thicknesses of the tissue, a triangular wedge of skin and cartilage was resected on the medial edge of the antihelical fold, into the concha floor cartilage. The cartilage also was approximated with 5-0 Maxon suture. Following good approximation and equalization of the cartilage repair, the anterior skin was then repaired with 5-0 nylon, as was the helical rim. Posteriorly, the skin was approximated also with 5-0 nylon. This produced an incision extending from the concha floor, across the anterior ear, across the helical rim, and onto the posterior ear, nearly to the sulcus. Adaptic gauze, without antibiotic ointment, and cotton dressings, were then applied and fixed with Hypafix tape. 

The patient tolerated the procedure quite well. The ear looked slightly smaller, but maintained a normal contour. 

Thanks!!


----------



## ARCPC9491 (Mar 31, 2009)

Look at 69310 - Reconstruction of external auditory canal

I'd say the debridement is inclusive.


----------



## magnolia1 (Mar 31, 2009)

The first issue I have with the use of 14300 is the defect measurements noted in your OP report. Millimeters are noted, not centimeters and the numbers do not convert to more than 30 centimeters.

Secondly, in reviewing the OP report several times, I do not see the word "flap" or "creation of a flap" in the body of the report.

Look at 15760.


----------



## FTessaBartels (Mar 31, 2009)

*69399*

I am leaning towards the unlisted code. I've gone back and forth on this one ... 

I did consider 69310, but since that is for the external auditory canal, and this reconstruction seems to be primarily for the hellical rim, I'm just not sure. 

I would definitely base my fee for 69399 on 69310.

Interesting case. Let us know what you finally decide (and if you get paid.)

F Tessa Bartels, CPC, CEMC


----------



## elenax (Apr 1, 2009)

Thank you all!!!!


----------



## magnolia1 (Apr 1, 2009)

I have looked at this again, and am leaning toward the "unlisted" code also.


----------

