Hey everyone....
I really could use some guidance on this case for a cup ear deformity reconstruction....
I have chosen cpt code 15732, but I am not sure what other codes I should include I keep going back and forth....
PREOPERATIVE DIAGNOSIS: Cup-ear deformity, left ear.
POSTOPERATIVE DIAGNOSIS: Cup-ear deformity, left ear.
PROCEDURE PERFORMED: Reconstruction of _____ ear with excision of
abnormal cartilage; fasciocutaneous flap creation for creation of
antihelix; complex closure of ear.
PROCEDURE IN DETAIL: Under general anesthesia, the patient was
prepped and draped in a sterile fashion.
A postauricular incision was made to address the cup-ear deformity
after injection of Marcaine with epinephrine.
Abnormal skin was removed from this area. The patient had complete
lack of an antihelix, which had to be fashioned. Straight Keith
needles were used to identify the portions around the antihelix that
were present. A cartilage-fasciocutaneous flap based on preauricular
vessels and superficial temporal artery was fashioned. A tube flap
of cartilage was outlined and cut, and left attached to its vascular
pedicle. A cartilaginous tube was then rolled onto itself and held
in place after making multiple back-cuts and shaping the cartilage,
held in place with 5-0 clear nylon sutures. A total of 5 sutures
were used to hold the tube. There was a bulging of the conchal bowl,
which then required debridement of the conchal bowl cartilaginous
mass, and the re-sewing and reconstruction of the bowl with PDS.
Conchal-mastoid suturing was also carried out. Following this, the
post-auricular incision was closed in a complex pattern, taking a
complex, stellate, irregular wound, cutting, tailoring and
linearizing it with multiple layers of absorbable suture and quilting
sutures.
The patient tolerated the procedure well. There were no
complications. Blood loss during the case was minimal. The patient
was sent to Recovery in good condition.
I really could use some guidance on this case for a cup ear deformity reconstruction....
I have chosen cpt code 15732, but I am not sure what other codes I should include I keep going back and forth....
PREOPERATIVE DIAGNOSIS: Cup-ear deformity, left ear.
POSTOPERATIVE DIAGNOSIS: Cup-ear deformity, left ear.
PROCEDURE PERFORMED: Reconstruction of _____ ear with excision of
abnormal cartilage; fasciocutaneous flap creation for creation of
antihelix; complex closure of ear.
PROCEDURE IN DETAIL: Under general anesthesia, the patient was
prepped and draped in a sterile fashion.
A postauricular incision was made to address the cup-ear deformity
after injection of Marcaine with epinephrine.
Abnormal skin was removed from this area. The patient had complete
lack of an antihelix, which had to be fashioned. Straight Keith
needles were used to identify the portions around the antihelix that
were present. A cartilage-fasciocutaneous flap based on preauricular
vessels and superficial temporal artery was fashioned. A tube flap
of cartilage was outlined and cut, and left attached to its vascular
pedicle. A cartilaginous tube was then rolled onto itself and held
in place after making multiple back-cuts and shaping the cartilage,
held in place with 5-0 clear nylon sutures. A total of 5 sutures
were used to hold the tube. There was a bulging of the conchal bowl,
which then required debridement of the conchal bowl cartilaginous
mass, and the re-sewing and reconstruction of the bowl with PDS.
Conchal-mastoid suturing was also carried out. Following this, the
post-auricular incision was closed in a complex pattern, taking a
complex, stellate, irregular wound, cutting, tailoring and
linearizing it with multiple layers of absorbable suture and quilting
sutures.
The patient tolerated the procedure well. There were no
complications. Blood loss during the case was minimal. The patient
was sent to Recovery in good condition.