Wiki Infratemporal space abscess?

[Alyssaw80107]

I'm having a hard time settling on a code for this procedure.

I&D of infratemporal space abscess via trans oral approach

PT had dental extraction of right 2nd and 3rd molars. Later, presented to ED with facial swelling, CT showed abscess lateral to maxilla extending into infratemporal fossa.
Incision was made through mucosa, and carried down to bone.
Free elevator was used to elevate mucosa and soft tissue lateral and posterior to maxilla with care to stay on bone.
Purulent fluid was drained. Wound was irrigated and drain placed.

 

[jackjones62]

Have your provider look at CPT 31040, I think this might be the way to go.

31040 - Pterygomaxillary fossa surgery, any approach
In this procedure, the provider uses any approach for a surgery involving the pterygomaxillary fossa, a trench–like structure roughly located between the upper jaw and orbit of the eye.

Clinical Responsibility
When the patient is appropriately prepped and anesthetized, the provider begins the approach to the pterygomaxillary fossa. In a typical procedure, he makes an intraoral incision in the parapharyngeal space. The provider carries this incision across the maxilla exposing the anterior wall of the maxilla, which is the upper jaw. He then also creates an opening in the posterior wall of the maxilla, approaching the pterygomaxillary fossa. He then performs the required surgery, such as removing a lesion in the fossa and tying the vidian nerves and maxillary artery in the fossa. The provider then closes the incision in the mouth with sutures in a single layer. The goal of the procedure is to treat any tumor or abscess present in the parapharyngeal space.

 

[Alyssaw80107]

Have your provider look at CPT 31040, I think this might be the way to go.

31040 - Pterygomaxillary fossa surgery, any approach
In this procedure, the provider uses any approach for a surgery involving the pterygomaxillary fossa, a trench–like structure roughly located between the upper jaw and orbit of the eye.

Clinical Responsibility
When the patient is appropriately prepped and anesthetized, the provider begins the approach to the pterygomaxillary fossa. In a typical procedure, he makes an intraoral incision in the parapharyngeal space. The provider carries this incision across the maxilla exposing the anterior wall of the maxilla, which is the upper jaw. He then also creates an opening in the posterior wall of the maxilla, approaching the pterygomaxillary fossa. He then performs the required surgery, such as removing a lesion in the fossa and tying the vidian nerves and maxillary artery in the fossa. The provider then closes the incision in the mouth with sutures in a single layer. The goal of the procedure is to treat any tumor or abscess present in the parapharyngeal space.

Thank you, I forgot to follow up. The provider liked this one and insurance paid.