Otolaryngology Coding Alert
Reader Question:
Include Cholesteatoma Removal in Procedure
Published on Sun Feb 01, 2004
Question: Under general anesthesia, an otolaryngologist explores a chronic otitis media patient's middle ear through a canal incision. During the middle-ear exploration, he removes keratinous debris. May I separately report the debris removal?
Mississippi Subscriber
Answer: No, you shouldn't bill for the debris removal. The debris removal is from a cholesteatoma, a benign tumor filled with desquamating debris. CPT contains no code for this procedure and considers the removal incidental to the middle-ear exploration.
However, you should code for the exploration with 69440 (Middle-ear exploration through postauricular or ear canal incision). Link 69440 to 385.32 (Cholesteatoma of middle ear).
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