Camille Posted Tue 17th of March, 2020 18:35:09 PM
Performed: Complete Mastoidectomy with transmastoid pluggin of labyrithine fistula (superior semicircular canal dehiscence), repair of tegmen defects transmastoid. Excerpt from Op Note: "A drill was then used to perform a complete mastoidectomy. The tegmen mastoideum, posterior fossa dural plate, lateral dural sinus, lateral sinus, lateral semicircular circular canal, posterior semicircular canal, and superior semicircular canal, and fallopian canal identified and preserved. There were multiple defects in the tegmen which showed no sign of CSF leakage. The facial nerve was not dehiscent. The crus commune was then identified.
Pericranium was then harvested as was bone dust and cut into small pieces for later plugging. Small balls of bone wax.
Using a 2 mm diamond burr, the crus commune next the endoscopy was exposed at the amputated end of the superior semicircular canal without violating the ampulla. Was blue lined and then the bone was carefully taken off of the endosteum using a Rosen needle. Pericranium was then packed into the wound sealing off the endolymphatic space as completely as possible followed by a small pate of bone wax with bone dust. Pericranium followed by the bone dust and bone wax was used to compress the endolymphatic space with care being taken not to damage the ampulla. The entire subacuate area and both sides of plugging within bolster with 1 more layer of bone wax." QUESTION: CPT 69605 INCLUDES A REVISED MASTOIDECTOMY AND 69530 INCLUDES A RADICAL MASTOIDECTOMY. IS THERE A MORE DEFINITIVE CPT CODE YOU WOULD ADVISE? THANK YOU!
SuperCoder Answered Wed 18th of March, 2020 02:18:11 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.
Camille Posted Wed 18th of March, 2020 12:47:24 PM
I did not ask you to code the note. I will rephrase my question: When a surgeon performs a Complete Mastoidectomy with transmastoid plugging of labyrithine fistula (superior semicircular canal dehiscence), repair of tegmen defects transmastoid, CPT 69605 would be accurate except it is not a Revised Mastoidectomy. Instead, is 69530 appropriate (even though it includes a Radical instead of Complete Mastoidectomy)? Thank you, kindly.
SuperCoder Answered Thu 19th of March, 2020 03:38:31 AM
Thank you for rephrasing the question.
CPT code 69530 would be the most appropriate CPT code for the provided documentation. We cannot consider CPT code 69605 because it is a revision mastidectomy code and hence would not be an appropriate code to use.
Camille Posted Thu 19th of March, 2020 23:15:46 PM
You're welcome-sorry for the confusion! Thank you, kindly!
SuperCoder Answered Fri 20th of March, 2020 01:33:46 AM
Thank you, happy to help.