Otolaryngology Coding Alert

Question: I need help in coding the following physician's report. What CPT and ICD-9 code would be appropriate?

NAME OF OPERATION: Biopsy left tonsil with frozen section.

PREOPERATIVE DIAGNOSIS: Left tonsil lesion, probable carcinoma.

POSTOPERATIVE DIAGNOSIS: Left tonsil lesion, benign.

FINDINGS: It was edematous inferior pole of the left tonsil. It also was moderately indurated. There was no evidence of an exophytic lesion nor any erosion. There were no palpable lymph nodes in the neck.

PROCEDURE: The patient was placed under general anesthesia and after orotracheal intubation, the self retaining mouth gag was inserted in the mouth and anchored to the Mayo stand. The left tonsil and right tonsil were palpated and examined visually. There was some induration in the inferior pole of the left tonsil and it appeared more edematous than the right. We used a punch biopsy to take two biopsies of the indurated area and sent them for frozen section. Bleeding was controlled with the 2-0 plain suture ligature. While waiting for the pathology report, we passed a Salem sump catheter in the mouth down into the stomach and emptied the stomach contents. We then removed the catheter. We suctioned the nasopharynx by each nostril. At that point we received the biopsy report of edema and irritation but no evidence of malignancy. Since the pharynx, hypopharynx, and nasopharynx were then hemostatic as well as dry, we removed the self retaining mouth gag and procedure was terminated. Estimated blood loss was less than 5 ml. Patient tolerated he procedure well and was taken to the recovery room in satisfactory condition.

Illinois Subscriber

Answer: You should opt for 42800 (Biopsy; oropharynx). This code and and 42802 (... hypopharynx) describe biopsy without use of a scope. Link 42800 to the diagnosis code 210.5 (Benign neoplasm of tonsil) to illustrate benign left tonsil lesion.

Payout: You should expect approximately $114.50 payment based on the nongeographic adjusted Medicare fee schedule when coding 42800, based on the code's 4.7 RVUs multiplied by 2011's conversion factor of 33.9764.