Wiki 31536 or 31541

[codedog]

We have a disareement here, one coder says 31541 while other is saying 31536, what do you think ? thank for your time

Patient was admitted with hoarseness and recurrent laryngeal papillomata. has undergone multiple laser laryngoscopy procedures for laryngeal papillomata since early childhood, On this admission, CO2 laser direct microlaryngoscopy and biopsy was performed without incident. Papillomata were present in the anterior one-third of the left true vocal cord and the anterior commissure, on the superior surface. No other lesions were noted. The base of the lesions was ablated with the CO2 laser at a setting of 5 watts.

postoperative course was uneventful and was discharged ambulatory on oral Orapred,

 

[fmao223]

I say you should bill 31541.

 

[nsteinhauser]

The op note says both.....first it says "biopsy was performed without incident" ...which would point me to 31536. But then it says "base of the lesions was ablated"....which sounds like the lesions are gone, or at least gone for now ...so what was there was essentially excised and/or removed, which would lead me to 31541. I would agree with the 31541.

 

[codedog]

thank yall