AN2114
Guru
I'm second guessing myself on this report and wanted to get another opinion to make sure I'm coding this right. I have code 42420 for total parotidectomy, but the doctor said he also did a meatoplasty. From my research, it looks like a duplicated auditory canal can be from a branchial cleft cyst. So should I just code this as 42420? or should I also code for the meatoplasty as well? But unless I'm missing something, I'm only seeing that the auricular cartilage defect was closed so I feel like I don't have enough supporting documentation to code for the ear. Any advice on this report would be helpful!
Postop diagnosis: left 1st branchial cleft/parotid mass, duplicated external auditory canal
Procedures: Left total parotidectomy with facial nerve microdissection, left meatoplasty, primary complex closure, removal of congenital branchial clef mass/duplicated external auditory canal, facial nerve monitoring
Operative findings: Fistulous tract present within skin overlying left parotid gland that tracked underneath the skin into a 1 cm diameter cartilaginous tract that was partially adherent to deep lobe of parotid and adherent to underlying masseter muscle and tracked completely to the posterior cartilaginous EAC. Tempral-zygomatic branch of facial nerve was stretched superficial to the cartilaginous branchial cleft remnant.
Procedure details: The patient was brought to the operating room, was placed in supine position. A timeout was called indicating the correct patient and procedure. General anesthesia was begin via face mask technique and patient was intubated. No long term paralytics were used by anesthesia team. Patients head was then turned 90 degrees to the left. Surgical timeout was performed and all in room were in agreement. Facial nerve probes were then placed by the monitoring team within the mentalis, orbicular oris, orbicularis oculi and frontalis muscles. Proper functioning of the facial nerve system was confirmed by monitoring team. Using a marking pen a small elipse was drawn around the superficial fistula and a modified blair incision was marked. 3cc of 1% lidocaine with 1:100,000 epinephrine was injected just deep to the dermis of the skin with care taken not to inject deep. Patient was then prepped and draped in normal sterile fashion.
A size zero lacrimal probe was then placed through the skin fistula and advanced greater than 2 cm into a cystic sac. Using a 15 blade the modified blair incision was completed with care taken to dissect just deep to the dermis. Using a combination of pickups and a Metz scissor a cervico facial flap was elevated between the SMAS and the underlying parotid fascia. During this dissection any structure of concern was stimulated using the facial nerve probe. The flap was elevated anteriorly to the level of the fistula confirmed via lacrimal probe placement. Once the flap was elevated attention was turned towards the accurate identification of the facial nerve. A plane of dissection was created between the tragal cartilage and the anteriorly located parotid tissue. The cartilage of the ear was found to be extremely distorted in contour with multiple area of cartilage extending anterior. After dissecting several milimeters adjacent to the tragal cartilage an area of cartilage was encountered that appeared cylindrical in nature and appeared to extend within the parotid tissue approximately 6-7cm to the area of the fistulous tract within the skin. It was determined that there was a direct connection between the skin fistula and the cartilaginous portion of the EAC, although the skin overlying the EAC cartilage was intact. While carefully dissecting just lateral to this cartilage tissue we came upon a nerve traveling from inferior to superior that was very superficial. The nerve was stimulated using facial nerve probe and found to be the termporal-zygomatic root/branch of the facial nerve. Extreme care was taken not to damage this nerve. The nerve was then traced slightly inferiorly using a Mccabe dissector and when stimulated also registered mentalis and orbicular oris muscles. Attention was then turned towards identification of the main trunk of facial nerve as it exits the stylomastoid foreman. Using the tragal pointer and tympanomastoid suture line as landmarks careful dissection was commenced to remove tissue lying lateral to the tympanomastoid suture line. Due to severe malformations of the auricular cartilage due to the presence of the branchial cleft anomaly the main trunk of the facial nerve was not determined to be too risky to identify. Decision was made instead to use the known peripheral branches of the facial nerve in combination with careful dissection and facial nerve probe stimulation to free the cartilaginous defect from the parotid bed. The cartilaginous connection of the branchial cleft remnant was dissected free from its connection to the cartilaginous EAC with a small auricular cartilage defect left in place. The branchial cleft remnant was then carefully dissected from posterior to anterior. An elipse incision was made surrounding the fistulous tract in the skin and it was delivered medial to the cervico facial flap. The branchial cleft remnant was freed from underlying masseter muscle with care taken not to injure any branches of the facial nerve. The congenital remnant was then removed from the parotid tissue bed and the peripheral branches of the facial nerve were stimulated with positive simulations noted on mentalis, orbicular oris, orbicularis oculi and frontalis. The bed was irrigated. The exposed facial nerve was covered with bacitracin soaked gelfoam. The elipse incision in the skin was closed using a single 4-0 deep vicryl and two 5-0 interrupted monocryl sutures. The auricular cartilage defect was closed the multiple 4-0 vicryl sutures and a piece of ciprodex gelfoam and bactracin soaked cotton ball were placed in the EAC. The modified blair incision was closed deep with 4-0 vicryl and running subcutaneous 5-0 monocryl. A small 1/4 inch penrose drain was placed in the inferior portion of the blair incision and tunneled in the wound and secured with a single 2-0 nylon suture. Masticel and steri strips were placed over the skin with a jaw braw dressing placed.
Specimen removed: 1st branchial cleft cyst, left parotid
Postop diagnosis: left 1st branchial cleft/parotid mass, duplicated external auditory canal
Procedures: Left total parotidectomy with facial nerve microdissection, left meatoplasty, primary complex closure, removal of congenital branchial clef mass/duplicated external auditory canal, facial nerve monitoring
Operative findings: Fistulous tract present within skin overlying left parotid gland that tracked underneath the skin into a 1 cm diameter cartilaginous tract that was partially adherent to deep lobe of parotid and adherent to underlying masseter muscle and tracked completely to the posterior cartilaginous EAC. Tempral-zygomatic branch of facial nerve was stretched superficial to the cartilaginous branchial cleft remnant.
Procedure details: The patient was brought to the operating room, was placed in supine position. A timeout was called indicating the correct patient and procedure. General anesthesia was begin via face mask technique and patient was intubated. No long term paralytics were used by anesthesia team. Patients head was then turned 90 degrees to the left. Surgical timeout was performed and all in room were in agreement. Facial nerve probes were then placed by the monitoring team within the mentalis, orbicular oris, orbicularis oculi and frontalis muscles. Proper functioning of the facial nerve system was confirmed by monitoring team. Using a marking pen a small elipse was drawn around the superficial fistula and a modified blair incision was marked. 3cc of 1% lidocaine with 1:100,000 epinephrine was injected just deep to the dermis of the skin with care taken not to inject deep. Patient was then prepped and draped in normal sterile fashion.
A size zero lacrimal probe was then placed through the skin fistula and advanced greater than 2 cm into a cystic sac. Using a 15 blade the modified blair incision was completed with care taken to dissect just deep to the dermis. Using a combination of pickups and a Metz scissor a cervico facial flap was elevated between the SMAS and the underlying parotid fascia. During this dissection any structure of concern was stimulated using the facial nerve probe. The flap was elevated anteriorly to the level of the fistula confirmed via lacrimal probe placement. Once the flap was elevated attention was turned towards the accurate identification of the facial nerve. A plane of dissection was created between the tragal cartilage and the anteriorly located parotid tissue. The cartilage of the ear was found to be extremely distorted in contour with multiple area of cartilage extending anterior. After dissecting several milimeters adjacent to the tragal cartilage an area of cartilage was encountered that appeared cylindrical in nature and appeared to extend within the parotid tissue approximately 6-7cm to the area of the fistulous tract within the skin. It was determined that there was a direct connection between the skin fistula and the cartilaginous portion of the EAC, although the skin overlying the EAC cartilage was intact. While carefully dissecting just lateral to this cartilage tissue we came upon a nerve traveling from inferior to superior that was very superficial. The nerve was stimulated using facial nerve probe and found to be the termporal-zygomatic root/branch of the facial nerve. Extreme care was taken not to damage this nerve. The nerve was then traced slightly inferiorly using a Mccabe dissector and when stimulated also registered mentalis and orbicular oris muscles. Attention was then turned towards identification of the main trunk of facial nerve as it exits the stylomastoid foreman. Using the tragal pointer and tympanomastoid suture line as landmarks careful dissection was commenced to remove tissue lying lateral to the tympanomastoid suture line. Due to severe malformations of the auricular cartilage due to the presence of the branchial cleft anomaly the main trunk of the facial nerve was not determined to be too risky to identify. Decision was made instead to use the known peripheral branches of the facial nerve in combination with careful dissection and facial nerve probe stimulation to free the cartilaginous defect from the parotid bed. The cartilaginous connection of the branchial cleft remnant was dissected free from its connection to the cartilaginous EAC with a small auricular cartilage defect left in place. The branchial cleft remnant was then carefully dissected from posterior to anterior. An elipse incision was made surrounding the fistulous tract in the skin and it was delivered medial to the cervico facial flap. The branchial cleft remnant was freed from underlying masseter muscle with care taken not to injure any branches of the facial nerve. The congenital remnant was then removed from the parotid tissue bed and the peripheral branches of the facial nerve were stimulated with positive simulations noted on mentalis, orbicular oris, orbicularis oculi and frontalis. The bed was irrigated. The exposed facial nerve was covered with bacitracin soaked gelfoam. The elipse incision in the skin was closed using a single 4-0 deep vicryl and two 5-0 interrupted monocryl sutures. The auricular cartilage defect was closed the multiple 4-0 vicryl sutures and a piece of ciprodex gelfoam and bactracin soaked cotton ball were placed in the EAC. The modified blair incision was closed deep with 4-0 vicryl and running subcutaneous 5-0 monocryl. A small 1/4 inch penrose drain was placed in the inferior portion of the blair incision and tunneled in the wound and secured with a single 2-0 nylon suture. Masticel and steri strips were placed over the skin with a jaw braw dressing placed.
Specimen removed: 1st branchial cleft cyst, left parotid