Otolaryngology Coding Alert

Question: My otolaryngologist's notes state, "With a microscopic exam, I was able to see a good deal of crusting in the mastoidectomy cavity. I cleaned the crusting using a loop curette, forceps and cotton-tipped applications coated with peroxide. I also observed granulation on an area of the sinodural angle. I cleaned this area with peroxide and cotton. I then used a silver nitrate applicator to cauterize to permit epithelization." Should I report 69220 or 69540?

California Subscriber

Answer: You should report 69220 (Debridement, mastoidectomy cavity, simple [e.g., routine cleaning]) for the cleaning procedure.

You should report 69540 (Excision aural polyp) only if the otolaryngologist removes an aural polyp. Your otolaryngologist doesn't note that he removed a polyp. He only describes cleaning the sinodural angle area and crusting from the mastoid cavity.