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History from: patient
Reason for visit: F/U procedure – e/o R ear canal lesion
Pt is here today for excison of right ear canal vascular lesion; has been there for several years and waxes and wanes in size; nontender but almost completely occludes the ear canal.
Right Ear
External: Pinna and periauricular area is normal.
Canal: bluish vascular lesion posterior lateral canal, almost completely occluding, able to debride cerumen and visualize intact TM
Tympanic Membrane: Tympanic membrane intact and mobile, no middle ear effusion or masses appreciated.
microscope used to examine ear
Consented for incision/debridement of right ear canal lesion.
[Procedure]
Cleansed with betadine, injected with 0.2 cc 1% xylo with 1:100kepi locally. 22 gauge needl aspirated –scant ; bacitracin ointment placed medially, then superficial skin debrided with cup forceps and cauterized with bipolar forceps and ear canal packed with Mycolog cream, cotton ball placed in meatal opening. Tolerated well.
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The physician is suggesting 69145 for removal of an ear canal lesion and 92504 for use of the microscope, but the notes indicate just a debridement. Since there is no specific code for debridement of the external ear, I have read that it may be best to code just the 92504 or code 69399 for an unlisted procedure and include notes w/ a code that has comparable work values.
However, the mention of cauterization leads me to think perhaps a destruction code is warranted (17004? 17110 due to mention of a vascular lesion?) Any help would be appreciated. Thanks in advance.