AN2114
Guru
I wanted an opinion on this report. The doctor says he did an excision and ablation of branchial cleft fistula and meatoplasty. I'm back and forth on which code would be more appropriate to code the 42810 or 69310. I wasn't sure if the documentation supports the meatoplasty and I should code just the 42810 or if I can code the meatoplasty.
Diagnosis: Right Otorrhea, right branchial cleft cyst/fistula
The patient was brought back to the OR and placed in the supine position. The patient was sedated and intubated by the anesthesia team. A Critical timeout was performed and when everyone was in agreement, the procedure commenced. The patient was turned 90 degrees to the patient's right. The patient was prepped and draped in usual fashion. The erythematous swelling was excised with an elliptical incision using a 15 blade around the cyst. Bipolar cautery was used to dissect around the cyst. The cyst was then freed off of the external auditory canal cartilage with a freer. Remnant infected skin was removed with curved iris scissors. A freer and Bipolar cautery was used to fully excise the cyst, making the ear canal wider. Any remnant tract was ablated using Bipolar cautery. The EAC was then filled with bacitracin ointment and a cotton ball was placed. At this point the surgery was completed and the patient was returned to anesthesia where she was extubated and brought to PACU in stable condition.
Diagnosis: Right Otorrhea, right branchial cleft cyst/fistula
The patient was brought back to the OR and placed in the supine position. The patient was sedated and intubated by the anesthesia team. A Critical timeout was performed and when everyone was in agreement, the procedure commenced. The patient was turned 90 degrees to the patient's right. The patient was prepped and draped in usual fashion. The erythematous swelling was excised with an elliptical incision using a 15 blade around the cyst. Bipolar cautery was used to dissect around the cyst. The cyst was then freed off of the external auditory canal cartilage with a freer. Remnant infected skin was removed with curved iris scissors. A freer and Bipolar cautery was used to fully excise the cyst, making the ear canal wider. Any remnant tract was ablated using Bipolar cautery. The EAC was then filled with bacitracin ointment and a cotton ball was placed. At this point the surgery was completed and the patient was returned to anesthesia where she was extubated and brought to PACU in stable condition.