Question

Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Left-sided tympanic perforation, secondary conductive hearing loss POSTOPERATIVE DIAGNOSIS: Left-sided tympanic perforation, secondary conductive hearing loss PROCEDURE PERFORMED: Left tympanoplasty with canaloplasty FINDINGS: Stenotic ear canal, significant narrowing of both the cartilaginous and bony segments. The bony segment underwent a canaloplasty. Large inferior perforation extending from the anterior annulus back to within 2 mm of the posterior annulus. INDICATIONS: The patient is a 6-year-old with a history of a large left tympanic perforation and has some evidence of hearing loss on audiogram. PROCEDURE IN DETAIL: The patient was brought into the room and placed under general anesthesia. The left ear was prepped and draped in the usual sterile fashion after intubation and confirmation of tube placement and securing the tube. The left postauricular sulcus was injected with 1 percent lidocaine with epinephrine, approximately 2 ml, and the ear was examined with a microscope. There was a large inferior perforation extending from the entire lower half of the eardrum, excluding the annulus anteriorly, and approximately to 1 to 2 mm of tympanic membrane posteriorly. The middle ear mucosa was dry, and there was no evidence of drainage or cholesteatoma. The ear canal was then injected in four corners with approximately 1 mL of 1 percent lidocaine with epinephrine, and vascular strip incisions were then made, including 6 o'clock and 12 o'clock incisions and a circumferential incision approximately 4 mm from the annular ring. A postauricular incision was then made approximately 2 mm behind the sulcus. This was carried down to the periosteum posteriorly and down to the temporalis fascia superiorly. The fascia was cleared of all of the areolar tissue, and a pocket was made under the skin flap. A small incision was made in the temporalis fascia approximately 1.5 cm, and then the temporalis fascia was elevated off of the muscle. This was resected approximately 1.5 cm squared and spread out on a Teflon block and then placed into a fascial clamp. This was then left to dry for the procedure until it was used.

Answer 1

ANSWER:

Left sided tympanic perforation : H72. 02

Secondary conductive hearing loss : H90. 2

Left tympanoplasty with canaloplasty : F13ZD3Z

Stenotic ear canal : H61. 303

Cartilagenous disorder : M94.9