Wiki Ear canal lesion debridement

[rgeib]

I'm looking for advice on the following procedure:
------------------------------------------------------
History from: patient
Reason for visit: F/U procedure - e/o R ear canal lesion

Pt is here today for excison of right ear canal vascular lesion; has been there for several years and waxes and wanes in size; nontender but almost completely occludes the ear canal.

Right Ear
External: Pinna and periauricular area is normal.
Canal: bluish vascular lesion posterior lateral canal, almost completely occluding, able to debride cerumen and visualize intact TM
Tympanic Membrane: Tympanic membrane intact and mobile, no middle ear effusion or masses appreciated.
microscope used to examine ear

Consented for incision/debridement of right ear canal lesion.

[Procedure]
Cleansed with betadine, injected with 0.2 cc 1% xylo with 1:100kepi locally. 22 gauge needl aspirated --scant ; bacitracin ointment placed medially, then superficial skin debrided with cup forceps and cauterized with bipolar forceps and ear canal packed with Mycolog cream, cotton ball placed in meatal opening. Tolerated well.
--------------------------------------------------------------
The physician is suggesting 69145 for removal of an ear canal lesion and 92504 for use of the microscope, but the notes indicate just a debridement. Since there is no specific code for debridement of the external ear, I have read that it may be best to code just the 92504 or code 69399 for an unlisted procedure and include notes w/ a code that has comparable work values.

However, the mention of cauterization leads me to think perhaps a destruction code is warranted (17004? 17110 due to mention of a vascular lesion?) Any help would be appreciated. Thanks in advance.

 

[JenniferB7]

Did the physician use cautery to control bleeding or destroy the vascular lesion. It is not clear from the documentation.

• If cautery was used to destroy the vascular lesion (and the record should be correctly amended), you could use CPT code 17106. CPT 92504 will be bundled into the more extensive procedure (17106).
• If done to control bleeding, you may want to look at CPT 97597. AAPC has a great article on this: https://www.aapc.com/blog/35439-revitalize-wound-care-reporting/. This seems to be the best code to described the procedure; however, the lack of any documented "cutting or excision" of tissue may prevent you from being able to report this code.

I would get clarification from the physician to determine the best direction to go. If your physician insists that the current documentation is correct, then at best, you can code for a fine needle aspiration (CPT 10021) if the scant specimen was sent to the lab for analysis or bill an unlisted code.

Hope that helps!