martnel
Guest
How would y'all code this? I am stuck on 69633, booked with 69660....
ANESTHESIA:
General
PREOPERATIVE DIAGNOSES:
Ossicular chain discontinuity; erosion of the lenticular process of the incus, right
POSTOPERATIVE DIAGNOSIS:
Ossicular chain discontinuity; erosion of the lenticular process of the incus, right
PROCEDURE:
Middle ear exploration with placement of porous hydroxyapatite partial ossicular replacement prosthesis, right.
PAST HISTORY:
Two year history of hearing loss.
DESCRIPTION OF PROCEDURE:
Under general anesthesia, the right ear was prepped and draped as a sterile field. Standard canal injections were made with 2% Xylocaine with epinephrine (1:50,000).
Using an operating microscope, a speculum and speculum holder, the tympanic membrane was noted to be intact and normal in appearance. The tympanomeatal flap was elevated. The middle ear appeared normal. There was no evidence of active infection. There was a complete erosion of the lenticular process of the incus, resulting in an ossicular chain discontinuity. The stapes was intact and mobile. The malleus was intact and mobile. The body of the incus was displaced superiorly into the antrum. Small portions of moistened Gelfoam were placed around the stapes in the middle ear. A porous hydroxyapatite partial ossicular replacement prosthesis was placed between the mobile stapes and the mobile malleus handle/tympanic membrane without difficulty. The tympanomeatal flap was replaced and a small portion of Neosporin soaked Gelfoam placed in the external auditory canal. The speculum and speculum holder were removed. A cotton ball was placed in the meatus and the external auditory canal.
The patient was awakened in stable condition with normal facial nerve function
ANESTHESIA:
General
PREOPERATIVE DIAGNOSES:
Ossicular chain discontinuity; erosion of the lenticular process of the incus, right
POSTOPERATIVE DIAGNOSIS:
Ossicular chain discontinuity; erosion of the lenticular process of the incus, right
PROCEDURE:
Middle ear exploration with placement of porous hydroxyapatite partial ossicular replacement prosthesis, right.
PAST HISTORY:
Two year history of hearing loss.
DESCRIPTION OF PROCEDURE:
Under general anesthesia, the right ear was prepped and draped as a sterile field. Standard canal injections were made with 2% Xylocaine with epinephrine (1:50,000).
Using an operating microscope, a speculum and speculum holder, the tympanic membrane was noted to be intact and normal in appearance. The tympanomeatal flap was elevated. The middle ear appeared normal. There was no evidence of active infection. There was a complete erosion of the lenticular process of the incus, resulting in an ossicular chain discontinuity. The stapes was intact and mobile. The malleus was intact and mobile. The body of the incus was displaced superiorly into the antrum. Small portions of moistened Gelfoam were placed around the stapes in the middle ear. A porous hydroxyapatite partial ossicular replacement prosthesis was placed between the mobile stapes and the mobile malleus handle/tympanic membrane without difficulty. The tympanomeatal flap was replaced and a small portion of Neosporin soaked Gelfoam placed in the external auditory canal. The speculum and speculum holder were removed. A cotton ball was placed in the meatus and the external auditory canal.
The patient was awakened in stable condition with normal facial nerve function
