Question: What is the code for treatment of cauliflower ear? One of our physicians says he performed an incision and drainage and then sutured the ear together with a drain in it.
Answer: A "cauliflower ear" is a post-traumatic deformity of the outer ear and is common in wrestlers and boxers, whose ears are regularly traumatized by their sport. Trauma to the ear can cause a blood clot underneath the skin. The clot disrupts the blood supply to the cartilage, which, if not promptly treated, will cause the cartilage to die and contract resulting in the shriveled outer-ear deformity known as cauliflower ear. The deformity, which is permanent, requires plastic surgery to correct. While internists are not likely to treat the deformity known as a cauliflower ear, they often treat the acute auricular (ear) blood clot or hematoma that may lead to a cauliflower ear. Prompt treatment of the hematoma will prevent a cauliflower ear.
The ear hematoma is treated by an incision in the outer ear followed by drainage of the blood clot. Code 69000* (Drainage external ear, abscess or hematoma; simple) describes this procedure. The physician makes an incision to drain the hematoma and may insert a drain and packing. The skin is sutured, and a compression dressing is placed. Your description of the procedure performed leads us to believe that the primary diagnosis in your case is the acute condition, 380.31 (Hematoma of auricle or pinna), rather than the permanent deformity, 738.7 (Cauliflower ear).