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Question: Our otolaryngologist excised an ear canal lesion from a patient’s left ear. The op report stated they used a microscope to identify the lesion, which was located in the posterosuperior quadrant of the cartilaginous external auditory, before removing the lesion and sending it to pathology for a definitive diagnosis.

Given that the ear is made up of skin and cartilage, and that both are soft tissues, do I use 69145 or 11440 to code the op note?

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Answer: Even though the ear is, as you say, made up of skin and cartilage, you would not use an integumentary system code such as 11440 (Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less) to describe the procedure your otolaryngologist performed.

Instead, you would use 69145 (Excision soft tissue lesion, external auditory canal), appending laterality modifier LT (Left side) to code the work described by the op note. The code descriptor not only states the lesion the provider is excising is made of soft tissue, but also specifically states that the lesion is located in the ear canal. This is far more specific than the procedure described by 11440, which only tells you the service is a removal of a lesion from an unspecified location in or on the ear.

Caution: Even though your otolaryngologist used a binocular microscope as a part of the service, you should not apply code 92504 (Binocular microscopy (separate diagnostic procedure)) for the microscope examination. That’s because 92504 describes a diagnostic examination of the ears, which is separate from the service your otolaryngologist performed. As the otolaryngologist used the microscope to aid in the process of excising the lesion, the use of the microscope would be considered bundled with the 69145 service and would not be documented separately.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC