# Panendoscopy with biopsies & Tonsillectomy



## rgeib (Apr 28, 2017)

So I'm not 100% confident in my CPT codes for this op report:

PREOPERATIVE DIAGNOSIS:  Metastatic squamous cell carcinoma to the
    lymph node, right neck, unknown primary.

ANESTHESIA:  General endotracheal anesthesia.

    PROCEDURES PERFORMED:
    Panendoscopy with biopsies (rigid bronchoscopy, rigid laryngoscopy,
    rigid nasopharyngoscopy, rigid oropharyngoscopy, rigid esophagoscopy
    aborted due to anatomy).  Other procedures included right
    tonsillectomy, biopsies of the right base of tongue, and right
    nasopharynx.

    IV FLUIDS:
    Received 1400 mL lactated Ringer's, clindamycin 600 mg, and Tylenol
    1 g.

    EBL:
    Minimal.
SPECIMENS:
    Sent to pathology included right tonsil, right base of tongue,
    right nasopharynx, right lateral oropharyngeal hypopharyngeal area.

    INDICATIONS:
    This is a male with history of a 5 cm right neck mass
    with fine-needle aspirate done in the office consistent with
    findings of metastatic squamous cell carcinoma.  He has had a PET/CT
    scan, which revealed increased activity in the right level 2, 3
    lymph node basin, large 4+ cm mass.  MRI scan and CT scans likewise
    showed this mass.  No other significant lymphadenopathy was found
    nor any other increased activity abnormality.  He was taken to the
    operating room for diagnostic studies to determine etiology of the
    metastatic cancer.

    FINDINGS AT TIME OF SURGERY:
    The right tonsil had firmness measuring approximately 1.5 to 2 cm
    at its inferior deep aspect with removal of this.  It had a fibrotic
    appearance to it.  Questionable malignant appearance.  The rest of
    the examination was normal including nasal cavity bilateral,
    nasopharynx bilateral, oral cavity, oropharynx, hypopharynx, larynx,
    mainstem trachea, and mainstem bronchi.  The esophagoscopy could not
    be performed because of an anterior located esophagus per venting
    rigid esophagoscopy from being done.  No mass was seen however.

DESCRIPTION OF OPERATION:
    Procedure as follows; after adequate preoperative counseling and
    consent had been obtained, the patient was taken to the operating
    room, IV lines monitors placed per Anesthesia and general
    endotracheal anesthesia administered.  The patient was given
    medicines per Anesthesia.  He was turned 90 degrees away from
    Anesthesiology and shoulder roll placed and he was draped in usual
    fashion.  Time-out was taken by the operating team to confirm the
    patient identification, procedure, and site.  A visual examination
    of the oral cavity and oropharynx was performed as well as bimanual
    palpation of the oral cavity, tongue, floor of mouth, and neck.
    Findings revealed a 5 cm firm, hard, fixed mass in the right level
    2, 3 neck.  This was 5 x 3 cm.  The next portion of the procedure
    included putting a dental bite guard over his upper teeth.  These
    teeth were noted to be in good condition.  Minimal decay.  *Rigid
    laryngoscopy *was performed and noted to have normal oral cavity,
    pharynx, hypopharynx, and larynx.  No mass was visible.  No
    asymmetry.  There is no palpable right base of tonsil firmness.  No
    exophytic lesion was seen.  *A rigid bronchoscopy was then performed*.
    The balloon cuff was let down on the endotracheal tube as the rigid
    bronchoscope was passed over this into the trachea down to the
    carina and mainstem bronchi.  No pathology was noted on entrance nor
    exit.  *Rigid esophagoscopy was then attempted.  He was noted to have
    normal piriform sinuses, but the entrance into the esophagus was
    anteriorly located and with the patient anatomy was not able to pass
    the rigid endoscope into this opening without causing trauma and
    therefore this was aborted.*  No mass was seen though at the entrance
    of the esophagus.  A rigid nasal endoscopy was then performed after
    nasal cavity had been packed with cottonoid pledgets soaked in
    Neo-Synephrine lidocaine for over 10 minutes.  Removal of the
    packing pledgets and passage of the rigid nasal endoscope revealed
    normal nasal cavity and nasopharynx. * Biopsy was taken of the right
    lateral nasopharynx* with Tru-Cut forceps and this bleeding was
    controlled with a suction Bovie cautery.  Then, the patient was
    prepared for doing* tonsillectomy *using a mouth gag and suspension
    apparatus.  The patient was suspended on the Mayo tray, and the
    right tonsil capsule was injected with 0.5% Marcaine, 2 mL thereof
    and *the superior tonsillar pole was incised after the tonsil was
    retracted medially with curved tonsil clamps and the peritonsillar
    capsule was entered and dissection continued from superior to
    inferior direction obtaining hemostasis in the process.*  In the
    inferior aspect, he was noted to have a firm fibrotic appearing
    submucosal tissue that was partially removed with the removal of the
    tonsil.  Tonsil sponge soaked in 0.5% Marcaine and tannic acid was
    placed in the tonsil fossa for 3 minutes and then removed.  Good
    hemostasis confirmed.  *Further biopsy of this inferior most aspect
    of the tonsillar pole was done and sent for frozen pathology*, which
    did not show any malignant tissue.  Further bimanual palpation of
    this area revealed a slight firmness residual in this inferior
    aspect of the tonsillar pole extending down to the vallecula.
*Biopsies of the right posterior lateral base of tongue in this area
    was done for ruling out any extension into this area.*  No visible or
    palpable pathology was found however.  At this time, procedure was
    complete and orogastric tube was able to be placed and suctioning of
    the stomach revealed clear secretions.  The mouth gag was removed
    and the dental bite guard was removed and the patient was turned
    back to Anesthesia, allowed to awaken, was extubated, and taken to
    the recovery room in stable condition.  We will await final
    pathology report for determination of whether source of his
    metastatic disease was found.  Plan will be to have him be seen by
    radiation oncology and medical oncology for potential chemotherapy
    and radiation therapy.  A surgical salvage for any residual neck
    disease would be performed if necessary in the future.

So the best I've come up with is:

42826 for Tonsillectomy

31535-59 for rigid laryngoscopy w/ tongue & tonsil biopsies (mod-59 added to break bundle with 31622. This particular insurance has been known to accept this unbundling in the past)

43191-53 for rigid esophagoscopy (mod-53 added as notes show procedure was d/c'd)

31622 for rigid bronchoscopy

31237 for rigid nasopharyngoscopy with biopsy of nasopharynx:

Any input would be appreciated. This one has been stumping me for an entire afternoon. Thanks.


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## JenniferB7 (Apr 28, 2017)

You are close!

I would code it as follows:


31237 (RVU: 6.94) - Nasal Endoscopy with Biopsy

42826 (RVU: 6.92) - Tonsillectomy (includes tonsil biopsy)

31525-59 (RVU: 6.83) - Rigid laryngoscopy; diagnostic, except newborn 

31622 (RVU: 6.52) - Diagnostic Rigid Bronchoscopy

41105 (RVU: 4.67) - Base of Tongue Biopsy

43191-53 (RVU 4.29) - Rigid esophagoscopy, diagnostic 

The tonsil biopsy is included in the tonsillectomy.  You cannot bill for both an excision and biopsy of the same area.  It is one or the other.   

Also, there is no indication that the biopsy was done as part of the laryngoscopy.  The laryngoscope had been removed prior to the base of tongue biopsy, which was performed after the tonsillectomy.  Therefore, you bill the tongue biopsy as an open excision, 41105.

Hope that helps!


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## rgeib (Apr 28, 2017)

Thanks, Jennifer. This was extremely helpful in clearing up the areas I was stuck on.


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## JenniferB7 (Apr 29, 2017)

You are very welcome!


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## elsaee87 (Jun 17, 2020)

If a "scout" endoscopic procedure to evaluate the surgical field (e.g., confirmation of anatomic structures, assess extent of disease, confirmation of adequacy of surgical procedure such as tracheostomy) is performed at the same patient encounter as an open surgical procedure, the endoscopic procedure is not separately reportable.


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