Tanesha Posted Wed 28th of August, 2019 21:28:19 PM
Would you code 69641 for this note? 69436 bundled into 69641. OP Excerpt: The postauricular incision was made. The soft tissue overlying the mastoid was then reflected and held in place with self retaining retractors. Using continuous suction irrigation and cutting burs, a standard mastoid was then drilled. tegmen was found in its usual position, followed down towards the antrum. The mastoid was sclerotic. There was soft tissue completely blocking the antrum which was now removed. The horizontal canal was identified in its normal position and remained intact. Once this was performed the external ear canal was examined and an anterior inferior incision was made and a triune tube was placed.
SuperCoder Answered Thu 29th of August, 2019 10:51:35 AM
Thanks for your question,
Can you please let us know whether all or portion of mastoid bone was removed. Since, it is mentioned in the excerpt that mastoid was sclerotic, and there were soft tissue completely blocking the antrum which is removed.
Code 69641 suggests that the provider reconstructs the tympanic membrane, or eardrum, to fix a perforation and removes all or a portion of the mastoid. This might involve reconstruction of the ear canal, tympanic membrane repair, and or other surgeries of the middle ear. Reconstruction of the ossicular chain is not included in this procedure.
Tanesha Posted Thu 29th of August, 2019 16:07:11 PM
The only documentation is what is in the excerpt. The Title was "OPERATIVE PROCEDURES 1. Left tympanomastoidectomy." FINDINGS:
1. Poorly aerated mastoid with antral blockage on the Left side. It doesn't state partial or all. I may have to query.
Tanesha Posted Fri 30th of August, 2019 07:57:36 AM
I can see the tympanoplasty portion of 69641 doesn't really apply in this case as only tubes were placed. maybe an unlisted code?
SuperCoder Answered Fri 30th of August, 2019 09:00:54 AM
Thanks for the reply.
As per the above documentation the appropriate code for the above procedure performed is 69641.
The tympanoplasty code (69641) includes the tube placement, according to the National Correct Coding Initiative (NCCI). The edits bundle pressure equalizing (PE) tube placement code 69436 (Tympanostomy [requiring insertion of ventilating tube], general anesthesia) into tympanoplasty with mastoidectomy code. Therefore, you should not separately report 69436 to Medicare and payers that follow NCCI.
Hope this helps.
Tanesha Posted Fri 30th of August, 2019 10:00:12 AM
So, in your opinion, the tympanoplasty (CDR description) portion of 69641 is represented in the op note excerpt?
SuperCoder Answered Mon 02nd of September, 2019 07:16:03 AM
Thanks for your follow up query.
We did some further research and listed findings below.
- The title of the procedure suggests left typanomastoidectomy was performed. Per review of reports, it was found that tympanoplasty was not performed along with mastoidectomy. Therefore, we should only code for mastoidectomy.
- The provided codes 69641 and 69436 would not be the appropriate CPT codes to use in this case since the provided note does not match with the operative report excerpt.
- Code 69501 Trans mastoid antrostomy (simple mastoidectomy) states that the physician extends an incision behind the ear. The mastoid bone is then exposed and opened with a surgical drill. The infection or abnormal mucosal growth is then evacuated. A tube may be placed in the eardrum to drain any pus or secretions present in the middle ear. Antibiotics are then administered either orally or via intravenous route. This procedure is usually performed to treat cholesteatoma and subperiosteal abscess of mastoid.
- It appears CPT code 69501 is the closest code to the provided operative note excerpt.
Hope provided information would be satisfactory.
Please feel free to ask if you have any further questions.
Tanesha Posted Wed 04th of September, 2019 08:21:24 AM
Thank you for your response. The first code that was suggested was applied unfortunately. Is there a way these questions can be researched fully before giving a response to prevent any miscoded accounts?
SuperCoder Answered Thu 05th of September, 2019 08:47:30 AM
Thanks for your feedback.
Sometimes there are some scenarios which are confusing and require further research either when the complete information is not available or the question is misunderstood.
You are correct that complete research should be done before responding to prevent any miscoded accounts. We have taken you concern and feedback into our consideration.