Hi all, my ENT doc did multiple scopes, multiple biopsies, and I am interested to see how others would code this. It took me a while to decide on my final answer, taking into account the CCI Edits!
Let me know, please!
PREOPERTIVE DIAGNOSIS: Squamous cell Carcinoma of unknown primary with a right neck lymph node showing proven squamous cell carcinoma on fine needle aspiration.
ANESTHESIA: General Anesthesia
ESTIMATED BLOOD LOSS: Less Than 5mL
COMPLICATIONS: None
PROCEDURE: On 11/18/2015, under the care of the department of anesthesia, the patient was transferred back to the operative suite, placed under general endotracheal anesthesia. The patient first had esophagoscopy performed with the flexible esophagoscope with Dr. S with the subsequent procedure note to be completed by Dr. S.
After the esophagoscopy was performed, the patient then had the flexible bronchoscope inserted through the endotracheal tube with the endotracheal tube brought to the level of the vocal cords. Passage of the scope through the main stem bronchus showed no lesions, masses or abnormalities. Examination to the level of the carina again showed no lesions or abnormalities. Advancement to the right main stem bronchus showed the lobar take offs again clear of any lesions, masses or tumors. The identical procedure was carried out down the left main stem bronchus again with the lobar take offs showing no abnormalities or lesions. With the airway clear below the vocal cords, the scope was slowly withdrawn and attention was then turned to the direct laryngoscope. The patient did have the lighted laryngoscope inserted into the oral cavity with a mouth guard in place.
Advancement along the posterior palate was continued posteriorly to the soft palate and the uvula. Advancement into the posterior oropharynx showed no lesions or masses. Examination bilaterally of the tonsil area extending down into the vallecular, again no lesions or masses. The scope was slowly advanced to the level of the epiglottis which was lifted up, sliding under the epiglottis revealing the bilateral vocal cords and laryngeal region shoed no lesions or masses with the endotracheal tube in place. Further advancement to the piriform sinuses bilaterally, examination of the aryepiglottic folds and the surrounding structures again failed to reveal any lesions or abnormalities. With the laryngoscope completed, the scope was removed without difficulty.
The mouth guard was removed and attention was then turned to the biopsies. The patient did have the large adult tonsillectomy blade inserted in the oral cavity with the head being wrapped in the blue towels and hemostat?d. The patient had visualization of the tonsil area and biopsies with biopsy forceps were taken of both the right and left tonsil as well as the base of the tongue on both sides which were marked and sent to pathology. There was trace bleeding controlled with the coblation cautery to the bilateral tonsillar areas with no gross bleeding to the base of tongue biopsy sites. With the biopsies of the oropharynx, the tonsillectomy blade and McIver mouth retractor was desuspended from the Mayo stand, which had been previously suspended. It was removed from the oral cavity and attention was then turned to the nasal cavity.
The patient did have the zero degree scope under visualized on the overhead screen with the coupler in place, used to advance the zero degree scope through the right nasal cavity. Posterior advancement to the nasopharynx showed no gross lesions or masses. Bilaterally, no abnormalities were seen to the fossa Rosenmuller or other abnormalities. A cusp forceps were used to take a biopsy of the nasopharynx. There was noted to be trace bleeding that was self-controlled with Afrin soaked pledgets. With the nasopharynx biopsied, there was noted to be a little bit of suspicious tissue to the posterior aspect of the inferior turbinate on the right side. This was again biopsied with the through cutting forceps gaining a good portion which was sent to pathology. Pressure and Afrin soaked pledgets showed bleeding to be controlled with no further abnormalities. The nasal cavity and oropharynx were suctioned free of trace secretions and trace blood. The zero degree scope was removed from nasal cavity, and the procedure was officially terminated.
Let me know, please!
PREOPERTIVE DIAGNOSIS: Squamous cell Carcinoma of unknown primary with a right neck lymph node showing proven squamous cell carcinoma on fine needle aspiration.
ANESTHESIA: General Anesthesia
ESTIMATED BLOOD LOSS: Less Than 5mL
COMPLICATIONS: None
PROCEDURE: On 11/18/2015, under the care of the department of anesthesia, the patient was transferred back to the operative suite, placed under general endotracheal anesthesia. The patient first had esophagoscopy performed with the flexible esophagoscope with Dr. S with the subsequent procedure note to be completed by Dr. S.
After the esophagoscopy was performed, the patient then had the flexible bronchoscope inserted through the endotracheal tube with the endotracheal tube brought to the level of the vocal cords. Passage of the scope through the main stem bronchus showed no lesions, masses or abnormalities. Examination to the level of the carina again showed no lesions or abnormalities. Advancement to the right main stem bronchus showed the lobar take offs again clear of any lesions, masses or tumors. The identical procedure was carried out down the left main stem bronchus again with the lobar take offs showing no abnormalities or lesions. With the airway clear below the vocal cords, the scope was slowly withdrawn and attention was then turned to the direct laryngoscope. The patient did have the lighted laryngoscope inserted into the oral cavity with a mouth guard in place.
Advancement along the posterior palate was continued posteriorly to the soft palate and the uvula. Advancement into the posterior oropharynx showed no lesions or masses. Examination bilaterally of the tonsil area extending down into the vallecular, again no lesions or masses. The scope was slowly advanced to the level of the epiglottis which was lifted up, sliding under the epiglottis revealing the bilateral vocal cords and laryngeal region shoed no lesions or masses with the endotracheal tube in place. Further advancement to the piriform sinuses bilaterally, examination of the aryepiglottic folds and the surrounding structures again failed to reveal any lesions or abnormalities. With the laryngoscope completed, the scope was removed without difficulty.
The mouth guard was removed and attention was then turned to the biopsies. The patient did have the large adult tonsillectomy blade inserted in the oral cavity with the head being wrapped in the blue towels and hemostat?d. The patient had visualization of the tonsil area and biopsies with biopsy forceps were taken of both the right and left tonsil as well as the base of the tongue on both sides which were marked and sent to pathology. There was trace bleeding controlled with the coblation cautery to the bilateral tonsillar areas with no gross bleeding to the base of tongue biopsy sites. With the biopsies of the oropharynx, the tonsillectomy blade and McIver mouth retractor was desuspended from the Mayo stand, which had been previously suspended. It was removed from the oral cavity and attention was then turned to the nasal cavity.
The patient did have the zero degree scope under visualized on the overhead screen with the coupler in place, used to advance the zero degree scope through the right nasal cavity. Posterior advancement to the nasopharynx showed no gross lesions or masses. Bilaterally, no abnormalities were seen to the fossa Rosenmuller or other abnormalities. A cusp forceps were used to take a biopsy of the nasopharynx. There was noted to be trace bleeding that was self-controlled with Afrin soaked pledgets. With the nasopharynx biopsied, there was noted to be a little bit of suspicious tissue to the posterior aspect of the inferior turbinate on the right side. This was again biopsied with the through cutting forceps gaining a good portion which was sent to pathology. Pressure and Afrin soaked pledgets showed bleeding to be controlled with no further abnormalities. The nasal cavity and oropharynx were suctioned free of trace secretions and trace blood. The zero degree scope was removed from nasal cavity, and the procedure was officially terminated.