# New to ENT Coding- Op Note Question



## BABS37 (Oct 5, 2012)

Can someone tell me if I'm correct on this Op Note? I'm new to ENT coding and I'm trying to understand the terminology... completely out of my element. I came up with 68420, 31231, 10060...

Pre-op DX: facial abscess and dacryocystocele with dacryocystitis
Procedure: Nasal endoscopy w/excision and marsupialization of dacryocystocele and drainage of nasal discharge. 
I & D facial abscess

With the help of the nasal endoscope we were able to inspect the inferior meatus. Within the inferior meatus there was a cyst that was identified. The cyst was incised with the help of a small sickle blade. A 7300 blade was used for this purpose. Once the incision was made a large amount of purulent discharge was expressed by compression of the facial abscess externally. There was a foul smelling drainage which was aspirated and cultured at this point. We then irrigated and also removed with the aide of a biting forceps the residual wall of the cyst that was identified within the middle meatus. There was free flow of secretions and purulent discharge into the nasal cavity after doing so. (This seemed like 31231- if I can even charge that if there's enough documentation and 68420 for the dacryocystocele) We then proceeded with the external component. The facial structures were irrigated and washed and we identified a small area that was broken down skin over the malar eminence superiorly andn on compression some more discharge was expressed on to the face. We made sure that any residual purulent discharge was expressed externally as well. At this point the procedure was terminated. (10060)

Is this ok?


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## dawnygirl (Oct 22, 2012)

I think the correct code would be 31239, since the physician is using an endoscope to remove the obstructing cyst. Not sure I would code the 10060 because there was no incision-just drainage by compression. 68420 is an open procedure-stab incision.
Hope this helps!


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