AHA Coding Clinic® for HCPCS - 2020 Issue 1; Ask the Editor

Repair of encephalocele with mastoid obliteration

Patient with an encephalocele and a cerebrospinal fluid (CSF) leak which caused inflammation of the mastoid mucosa presents for transmastoid repair of the encephalocele with mastoid obliteration. A postauricular incision was made, the ear was undermined and a portion of the fascia was removed for use later. An additional incision was made exposing the mastoid and bone shavings were also taken for later use. Utilizing the operating microscope a mastoidectomy was performed with removal of bone from the mastoid cortex. Next, an 8mm encephalocele was treated via cauterization and was reduced. However, there was a large tegmen mastoideum defect. To ensure the tegmen mastoideum defect was repaired and the CSF leak was sealed, fascia and bone chips were utilized to fill the defect. Also, multilayered closure was performed with gelfoam, fascia, bone pate with fibrin glue placed in sheets to obliterate the mastoid cavity. The skin was closed in layers. Our facility wants to know which CPT code should be assigned for transmastoid repair of encephalocele with mastoid obliteration and bone grafts? Would CPT code 69670 be the appropriate code for the entire procedure or should it be coded to 62121? ...

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