The removal of most cholesteatomas of the tympanic membrane and middle ear during tympanostomy or tympanoplasty are incidental and should not be coded separately, coding experts say. Coders should read the operative report to see what specific steps were taken during a procedure to choose the best code. Further, reimbursement opportunities increase when anesthesia is administered.
Dorlands Medical Dictionary defines cholesteatoma as a cyst-like mass or benign tumor with a lining of stratified squamous epithelium, usually of keratinizing type, filled with desquamating debris frequently including cholesterol. They are found most commonly in the middle ear and mastoid region, usually after a trauma or infection that heals poorly.
Cholesteatomas also may be found on the tympanic membrane. These usually are associated with chronic infection of the middle ear. In the following operative report, the otolaryngologist encounters and excises a cholesteatoma (referred to in the operative note as a keratoma) on the patients outer eardrum (tympanic membrane), during the course of performing a tympanostomy.
Preoperative diagnosis: Bilateral chronic otitis media
Postoperative diagnosis: Same
Operation/procedure performed: Bilateral myringotomy and tubes
Anesthesia: General anesthesia
Description of procedure:
The patient was placed in the supine position, prepped and draped in the usual sterile fashion, under general anesthesia by mask. The right ear was visualized under a microscope after removing obstructing cerumen with the cerumen curet. The ear was irrigated with sterile saline solution. A myringotomy blade was used to make an antero-inferior radical myringotomy incision. A scant amount of fluid was suctioned from the middle ear space with a # 5 Frazier suction. A Pope-type myringotomy tube was inserted and Cortisporin Otic drops were applied. Attention was then directed to the left ear. Visualized under a microscope, obstructing cerumen was removed with a cerumen curet. The external auditory canal was irrigated with sterile saline solution and suctioned out with a # 5 suction. The tympanic membrane was inspected. There was a small antero-inferior retraction pocket that contained some keratinous debris. This was carefully removed with alligator forceps. A small keratin plug was sent for pathology. There was an area of atelectasis where this keratin plug was, and the myringotomy was made antero-inferiorly to excise a portion of this atelectatic area. After the myringotomy incision was made, # 5 suction was used to suction the middle ear space. A scant amount of fluid was encountered. A Pope-type myringotomy tube was inserted, and Cortisporin Otic drops were applied. At this point the procedure was terminated. The patient tolerated the procedure well and was taken to the recovery room in stable condition.