Camille Posted Sat 07th of December, 2019 21:53:12 PM
DX CONDUCTIVE HEARING LOSS, LEFT EAR, HX OF MASTOIDECTOMY LEFT EAR, PERF OF TYMPANIC MEMBRANE, LEFT EAR. EXCERPT FROM OP NOTE: "The postauricular area was injected with 1% lidocaine and 1:100,000 epinephrine, as was the ear canal. An endaural incision was created posteriorly from 11-5 o'clock. The cartilage graft from the prior procedure and that spanned middle flap was lifted in 1 piece. This was after suctioning some caseous debris from the external canal. I decided to proceed with the procedure since I do not think this represents active infection. There was dense adhesions throughout the middle ear and through the aditus at antrum and into the mastoid. After careful dissection there was no evidence of cholesteatoma. The surgical endoscopes at 0 and 30 degrees were deployed. There was no evidence of cholesteatoma in the middle ear or mastoid space. The stapes was very carefully dissected out.
There is a small crack in the stapes footplate which appeared to be from prior activity and was fibrosed over. A Dornhoffer total ossicular reconstruction prosthesis with a footplate she was placed on the footplate after sizing at the 5 mm in height. Please note that the tympanic membrane was lateralized stretching the tensor tympani tendon. A minimal amount of Gelfoam was placed posteriorly holding the prosthesis in place before placing the tympanic membrane and tympanomeatal flap with the cartilage intact back in its native position. Bactroban ointment was placed followed by 2 Floxin soaked otowicks in the ear canal."...QUESTION: Dr. states he/she performed an inside-out mastoidectomy and is coding 69644. I thought CPT 69633 due to placement of TORP and I don't find a mastoidectomy was performed per the procedure description. Please advise. Thanks very much!
SuperCoder Answered Mon 09th of December, 2019 03:43:07 AM
Thank you for your question.
As per the above documentation, it is not indicating that mastoidectomy was performed. CPT code 69644 includes the work performed as “Tympanoplasty with mastoidectomy”; however, the documentation, does not include the mastoidectomy was performed along with Tympanoplasty. Therefore, report CPT code 69633 (Tympanoplasty without mastoidectomy).
Hope that Helps!