# Need help -Tracheoscopy with biopsy



## Ventachic1 (Feb 16, 2009)

Need help coding Tracheoscopy and bronchoscopy with biopsies through the trach.  Have narrowed it down to 31615 for the scope portion, but how do I code the biopsies taken.


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## b.cobuzzi (Jul 15, 2009)

Can you put here what the procedure note says?  Was a laryngoscopy done also?


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## Barbara Vande Hey (Aug 24, 2022)

I have similar questions.. Note says "
Procedure: Flexible tracheoscopy via a tracheostomy tube and tracheostomy tube repositioning.

Preop diagnosis malposition tracheostomy tube and chronic respiratory failure

Postop diagnosis same

Description of procedure: Tracheostomy tube was malpositioned.  A flexible laryngoscope was passed via the tracheostomy tube after the inner cannula was removed.  We are able to see the lumen of the trachea.  The tracheostomy tube was pushed deeper in.  We performed the procedure with the assistance of anesthesia Dr. Ken.  We replaced the flexible laryngoscopy scope via the tracheostomy tube and the tracheostomy tube was in good position within the trachea where easily see the carina.  We suctioned the patient's oral cavity with the tube in with a flexible suction  suctioning the trachea.  There was significant clear secretions seen.  We tightened the tracheostomy ties.  Tracheostomy tube confirmed was in good position.

CONSULTATION ASSESSMENT: Chronic respiratory failure with a malpositioned/extruded tracheostomy tube.  Tracheostomy tube was repositioned and was in good position the patient was breathing easily on the ventilator.

TREATMENT PLAN: 

We reposition the tracheostomy tube and confirmed its good positioning with the flexible laryngoscope.  The patient has significant amount of clear secretions.  We asked that respiratory therapy confirm the appropriate pressure from the tracheostomy tube cuff.  We will asked the ER provider to evaluate the patient for his excessive secretions and confirm there is no other concerning findings that may require additional medical management.  Tracheostomy tube is in good position the patient is functioning and breathing well via his tracheostomy and respirator.  The patient may return to the care of his otolaryngology provider.  Follow-up as needed.


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## Barbara Vande Hey (Aug 24, 2022)

any help in coding this would be appreciated


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