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Code This!

Scenario Week of August 18, 2011:
View Current Scenario

Preoperative/postoperative diagnoses:
  1. Right chronic mastoiditis
  2. Right cholesteatoma
  3. Right chronic otorrhea

Operation performed:

  1. Right revision tympanomastoidectomy with facial nerve monitoring

Findings:

  1. Cholesteatoma noted in sinodural angle
  2. Large amounts of cholesteatoma seen in the epitympanic region
  3. Large amounts of middle ear granulation tissue and purulent otorrhea
  4. All ossicles were preserved
  5. Incudostapedial joint was disarticulated for better access into the middle ear cavity

Description of the operative procedure:

After obtaining consent, the patient was taken to the operating suite and underwent general anesthesia with an endotracheal tube in supine position. The patient was rotated to 180 degrees. The nerve integrity monitor for the facial nerve was connected in the usual fashion. Then 1 percent Xylocaine with 1:100,000 epinephrine was injected into the postauricular incision site and allowed to diffuse into the posterior superior vascular strip region. Adequate amount of time was allowed. The right ear was prepped and draped in the usual sterile fashion.

A #15 blade was used to create an incision through the original cicatrix on the first operation. This incision was carried up to the temporalis fascia. A temporalis fascial graft was obtained and set aside for routine drying procedure. Bovie suction cautery was used to create an incision along the linea temporalis and a second incision was made inferiorly up to the inferior aspect of the bony external auditory canal. This periosteal flap was then elevated anteriorly with a Joseph elevator. This allowed access up to the junction of the cartilaginous and bony external auditory canal. A #15 blade was used to create an incision through the cartilaginous aspect of the external auditory canal parallel to the bony external auditory canal. This allowed visualization into the external auditory canal. A ¼ inch Penrose drain was inserted through this incision and used in conjunction with the self-retaining retractor to hold the right ear in the forward direction. The mastoid cortex was further visualized after periosteal elevation. A #5 cutting bur was used to perform a mastoidectomy. The mastoid cavity was dissected anteriorly into the zygomatic root. The dissection was carried further posteriorly into the sinodural angle and inferiorly to the digastric insertion in the mastoid tip. Anteriorly, the dissection was performed medially to visualize the horizontal semicircular canal and fossa incudis. A #3 coarse diamond bur was used to further skeletonize posteriorly along the sigmoid sinus, superiorly along the tegmen tympani. A #.5 coarse diamond bur was used to dissect further into the zygomatic root and allow better access and visualization of the epitympanic region. Large amounts of cholesteatoma and granulation tissue were removed throughout the procedure. Upon adequate skeletonization and removal of cholesteatoma from the sinodural angle and epitympanum, attention was directed to the tympanic membrane. The tympanic membrane was very edematous. This was elevated from the annular groove anteriorly. Chorda tympani was visualized and preserved. Granulation tissue and polypoid masses were removed from the middle ear cavity. All tissue from the mastoid and middle ear cavity was sent to pathology for further evaluation. Further elevation of the tympanic membrane allowed visualization of the malleus and the incus.

The incudostapedial joint was seen and careful dissection allowed visualization of the stapes capitulum. Secondary to poor access, the incudostapedial joint was disjointed. The malleus and incus complex was held anteriorly as better access was obtained into the middle ear cavity for cholesteatoma removal.

Upon adequate removal of the cholesteatoma, irrigation was performed to assure a good connection between the middle ear cavity and mastoid. The malleus and incus complex were then replaced to their original position. The incus was placed into the fossa incudis and the incudostapedial joint was rejoined. A small amount of fibrin glue was injected over the IS joint. Gelfilm cut in small circles, was placed into the middle ear cavity, atop the promontory. Ciprodex-soaked Gelfoam was placed into the middle ear cavity. The temporalis fascia was placed underneath the original tympanic membrane anteriorly and brought out posteriorly along the bony external auditory canal. The Penrose drain and self-retaining retractors were removed. Under visualization with the microscope, the posterior cartilaginous external auditory canal and skin flap were replaced in their original position superficial to the temporalis fascia graft. Another layer of Ciprodex-soaked Gelfoam was placed lateral to the tympanic membrane and temporalis fascia graft.

The postauricular incision was closed in 3 layers with 3-0 Vicryl suture in an interrupted fashion. We started with the periosteal closure, then the dermal, and epidermal closure. The epidermis was closed with 5-0 fast gut suture in a running fashion. Antibiotic ointment was injected into the external auditory canal and a cotton ball was inserted into the right external auditory canal. A Glasscock ear dressing was then placed in the standard fashion. The patient tolerated the procedure well. No complication. The patient was then taken to postanesthesia care unit in satisfactory condition. Facial nerve testing by the anesthesiologist postoperatively demonstrated intact facial nerve.


How would this scenario be coded using 2011 codes?

The appropriate CPT coding for this procedure would be:

69645-RT Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction.

There are several options for reporting a tympanoplasty with mastoidectomy using codes 69641-69646. The codes with ossicular reconstruction are not appropriate as the operative report notes that the ossicular chain (incus, stapes, and malleus) was viewed and explored, but remained intact.

Although the procedure may not meet the standard definition of a radical procedure it is more complete than 69641 or 69643. The procedure described the extensive mastoidectomy with removal of the cholesteatoma from the mastoid and the middle ear. Extensive skeletonizing of the bony canal, incudostapedial joint disarticulation and repair for access, with fascia grafting were performed in addition to the services in the lesser tympanoplasty and mastoidectomy codes.

The RT modifier was appended to indicate that this was performed on the right ear.

An operating microscope is mentioned in the operative report. However code 69645 and 69990 trigger a CCI edit and may not be reported together.

The facial nerve monitoring is reported with code 95920 by the anesthesiologist.

The appropriate ICD-9-CM coding for this procedure would be:

383.1 Chronic mastoiditis

385.33 Cholesteatoma of middle ear and mastoid

388.69 Otorrhea, other

The codes are reported in the order listed by the surgeon for provider services.

The chronic mastoiditis is reported with 383.1 as opposed to acute mastoiditis (383.00-383.02). The cholesteatoma was of the middle ear and mastoid and is best represented by 385.33. Code 388.60 is used to report the chronic otorrhea.

 
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