Stacey Walden
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Hello, we are trying to ensure we are properly coding these two procedures. Any guidance is appreciated.
Patient originally presented with a complaint of a "cyst" in her ear. It was observed that she had a flesh colored growth superiorly obstructing entirety of right EAC. Wick placed and prednisone was prescribed. Upon follow-up the wick had fallen out but there was some improvement so another wick was placed. Another follow up revealed the right EAC with a fluctuant mass arising off superior EAC. Plan was to continue steroids and if no improvement we would excise the cyst.
Patient returned to the office and requested excision. The CPT billed was 69145 RT (Excision of damaged or diseased tissue from the external ear canal) but now we are concerned it should have been coded differently. Here is the procedure description: An 18 gauge needle was inserted into the mass at various angles to break apart loculations until the mass was succesfully reduced. Serosanguinous fluid was removed. Two wicks were placed in the EAC.
* Should this have been 69020 (draining an abscess in the external auditory canal - this code may also include inserting an ear wick)? Or billed as 10060 for incision and drainage?
In addition, at a subsequent follow-up the mass was unroofed and copious squamous debris was present. Some of the debris was removed, but not all. It was determined during examination that the mass was worrisome for a cholesteatoma, even though it previously presented as an infected epidermal inclusion cyst. * What would the CPT code be for this procedure?
Thank you!
Patient originally presented with a complaint of a "cyst" in her ear. It was observed that she had a flesh colored growth superiorly obstructing entirety of right EAC. Wick placed and prednisone was prescribed. Upon follow-up the wick had fallen out but there was some improvement so another wick was placed. Another follow up revealed the right EAC with a fluctuant mass arising off superior EAC. Plan was to continue steroids and if no improvement we would excise the cyst.
Patient returned to the office and requested excision. The CPT billed was 69145 RT (Excision of damaged or diseased tissue from the external ear canal) but now we are concerned it should have been coded differently. Here is the procedure description: An 18 gauge needle was inserted into the mass at various angles to break apart loculations until the mass was succesfully reduced. Serosanguinous fluid was removed. Two wicks were placed in the EAC.
* Should this have been 69020 (draining an abscess in the external auditory canal - this code may also include inserting an ear wick)? Or billed as 10060 for incision and drainage?
In addition, at a subsequent follow-up the mass was unroofed and copious squamous debris was present. Some of the debris was removed, but not all. It was determined during examination that the mass was worrisome for a cholesteatoma, even though it previously presented as an infected epidermal inclusion cyst. * What would the CPT code be for this procedure?
Thank you!