Can someone please help with this?
Posturuiculare incision, Exernal canal skin encountered. Temporoparietal fascia was harvested. Palva flap was harvested off mastoid cortex. Complete mastoidectomy was performed. Mastoid tegmen was identified. Bone of posterior auditory canal was thinned, air cells between posterior fossa dura and posterior semicurcular canal were taken down and skull base defects were encountered.There was an encephalocele extending from posterior fossa into the mastoid cavity which was cauterized There were two defects that were small within the posterior fossa dura. Small pieces of muscle and fat were harvested to plug the bony defect.
Physician used CPT 62121. I don't see anywhere in the office notes that she has had prior mastoidectomy.
Thanks,
Grace
Posturuiculare incision, Exernal canal skin encountered. Temporoparietal fascia was harvested. Palva flap was harvested off mastoid cortex. Complete mastoidectomy was performed. Mastoid tegmen was identified. Bone of posterior auditory canal was thinned, air cells between posterior fossa dura and posterior semicurcular canal were taken down and skull base defects were encountered.There was an encephalocele extending from posterior fossa into the mastoid cavity which was cauterized There were two defects that were small within the posterior fossa dura. Small pieces of muscle and fat were harvested to plug the bony defect.
Physician used CPT 62121. I don't see anywhere in the office notes that she has had prior mastoidectomy.
Thanks,
Grace