Jwindsor17
New
Please see op note below. The lesion that was removed was in the ear canal extending all the way down to the TM. I do not see a NCCI edit between 69145 & 69450. Is it appropriate to code them both for 1 lesion as it is within both anatomical locations?
PREOP/POSTOP DIAGNOSES: LEFT EAR CANAL LESION
PROCEDURES:
1. MICRODEBRIDEMENT WITH REMOVAL OF LEFT EAR CANAL LESION
2. LEFT EAR TYMPANOSTOMY WITHOUT PE TUBE PLACEMENT
ANESTHESIA: MAC
INDICATIONS: Ms. X is a 79 year old female who complains of not being able to hear well from the left ear, the patient was seen in the clinic and found to have a dry crusty mass in the left ear canal totally occluding the TM. Attempt at removal in the office was not successful due to discomfort. Due to these findings the patient was therefore indicated for the above procedure.
INTRAOPERATIVE FINDINGS: Severe dry desquamated epithelial tissue impacted in the left ear canal mixed with cerumen and it is impacted and adhered tightly to the left TM.
DESCRIPTION: The patient and Dr. T met in the preop holding area, perioperative course was discussed with the patient, informed consent was reviewed with the patient who has no further questions and wished to proceed. The patient was brought to the operating room and placed in the supine position on the operating table. The patient underwent satisfactory MAC anesthesia via IV sedation. The patient was prepped and draped in a standard sterile fashion. The left ear was examined under the operating microscope. A cerumen curette was used to remove some cerumen and after removing the cerumen there appears to be dry crusty lesion/mass that extends all the way down to the TM and is adhered tightly to the TM. Next, the alligator forceps was used to tease off the lesion from the TM and from the ear canal. After this was done, microdebridement was carried out until the all fragments were removed microscopically. The TM appears to have erythema. Therefore, the decision was made to perform an incision on the TM via tympanostomy. Gentle suction was carried out, there is no fluid. The decision was then made to conclude the procedure. The surgery was concluded. The patient was reversed from anesthesia. She was awake and transferred to recovery in stable condition.
ESTIMATED BLOOD LOSS: NONE
SURGICAL SPECIMEN: NONE
POSTOP COMPLICATIONS: NONE
DISPOSITION: The patient will be sent home with watchful observation and instructions in strict “dry ear” precautions. Return to see me in one week.
PREOP/POSTOP DIAGNOSES: LEFT EAR CANAL LESION
PROCEDURES:
1. MICRODEBRIDEMENT WITH REMOVAL OF LEFT EAR CANAL LESION
2. LEFT EAR TYMPANOSTOMY WITHOUT PE TUBE PLACEMENT
ANESTHESIA: MAC
INDICATIONS: Ms. X is a 79 year old female who complains of not being able to hear well from the left ear, the patient was seen in the clinic and found to have a dry crusty mass in the left ear canal totally occluding the TM. Attempt at removal in the office was not successful due to discomfort. Due to these findings the patient was therefore indicated for the above procedure.
INTRAOPERATIVE FINDINGS: Severe dry desquamated epithelial tissue impacted in the left ear canal mixed with cerumen and it is impacted and adhered tightly to the left TM.
DESCRIPTION: The patient and Dr. T met in the preop holding area, perioperative course was discussed with the patient, informed consent was reviewed with the patient who has no further questions and wished to proceed. The patient was brought to the operating room and placed in the supine position on the operating table. The patient underwent satisfactory MAC anesthesia via IV sedation. The patient was prepped and draped in a standard sterile fashion. The left ear was examined under the operating microscope. A cerumen curette was used to remove some cerumen and after removing the cerumen there appears to be dry crusty lesion/mass that extends all the way down to the TM and is adhered tightly to the TM. Next, the alligator forceps was used to tease off the lesion from the TM and from the ear canal. After this was done, microdebridement was carried out until the all fragments were removed microscopically. The TM appears to have erythema. Therefore, the decision was made to perform an incision on the TM via tympanostomy. Gentle suction was carried out, there is no fluid. The decision was then made to conclude the procedure. The surgery was concluded. The patient was reversed from anesthesia. She was awake and transferred to recovery in stable condition.
ESTIMATED BLOOD LOSS: NONE
SURGICAL SPECIMEN: NONE
POSTOP COMPLICATIONS: NONE
DISPOSITION: The patient will be sent home with watchful observation and instructions in strict “dry ear” precautions. Return to see me in one week.