Wiki Postauricular Abscess

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ieshiarenee

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My physician performed an I&D of a postauricular cyst, and him and I cannot seem to agree on the proper code to use. I suggested 10060, but he wasn't crazy about it. Do you mind taking a look at the op report and let me know what you think?


"The postauricular area was prepped and draped in the usual sterile fashion, and a small sub-centimeter incision was made, and some murky fluid was present and expressed. It was cultured. I then explored the abscess pocket with a small hemostat and broke up a fluid collection. The abscess seemed to track almost up to the conchal root. This was a somewhat atypical location for a preauricluar cyst, though it is possible that there was a small cyst present in that location which subsequently ruptured, causing an abscess in the postauricular region. I lavaged all of this with an antibiotic irrigation solution. A small amount of iodoform packing was then placed into the postauricular abscess, but I did not perform a formal excision of the pit at the helical root at this time. The patient was then lightened from anesthesia after a small dressing was placed and brought to the recovery room in good condition."


Thank you so much for your help.
Ieshia Cuspard, CPC
 
1) The physician may agree that CPT 69440 could be coded here. There was a middle ear exploration, right? Of course that would need a "postauricular OR ear canal incision"

2) Briefly consider the gauge of the needle/hemostat, as 10021 is fine needle (20-25 gauge) vs 10060/10061 is not specific to needle gauge. 10060 is abscess. to give a rationale for 10061 it needs to be "complicated" & we were taught in CPC class that "complicated" is foreign body or infection.
 
Thank you for your help!

The middle ear was not explored. Just the abscess in the post auricular area.

The description for 69440 states; Entering through the external ear canal opening or through a postauricular incision (behind the ear) and into the ear canal, the physician performs exploratory surgery of the middle ear. The eardrum is lifted posteriorly and the middle ear is explored including testing the mobility of the ossicular chain. No major treatment is rendered at this time. The eardrum and canal skin are repositioned and the canal is packed. Any postauricular incision is sutured.

I don't think that is the appropriate code for this encounter. Any other suggestions?
 
I would look to codes 69000 and 69005 as the physician notes that the track seemed to go almost to the conchal root and consideration of excision at the helical root. This indicates the procedure was more on the external ear than scalp.
 
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