AN2114
Guru
I wanted an opinion on what to do about this op report. From what I'm understanding there was a bilateral endoscopy and cautery on the right and packing bilaterally. I know code 31238 is the code for endoscopy with control of hemorrhage but can that code be used for packing so I can code that as bilateral? or I saw code 30901 says limited cautery and/or packing so should I code it as 31238-RT 30901-LT?
Procedure: Bilateral nasal endoscopy, nasal cautery, removal of nasal packing.
Details:
Patient was brought back to operative suite. Timeout was performed and all in agreement. Anesthesia was induced and patient intubated. Head of bed turned 90 degrees to right. Patient was prepped and draped in normal sterile fashion for sinus surgery. Left nasal packing removed. Two afrin soaked pledgets placed in nose and 1.5cc of lidocaine with 1:100,00 epi was injected into the nare. Bilateral nasal endoscopy performed and small amount of active bleeding noted on right anterior nasal septum but no active bleeding from left nare. No masses or tumors noted. Using 1 french suction bovi in setting of 8 right nasal septum was cauterized and small amount of silver nitrate used. Complete hemostasis achieved. Small piece of bacitracin soaked gelfoam placed in right nare and small piece of surgicel placed in left middle meatus. Both packing are dissolvable and do not have to be removed. Head of bed turned back to normal. Care of patient returned to anesthesia who extubated without complication. Taken to PACU in stable condition.
Procedure: Bilateral nasal endoscopy, nasal cautery, removal of nasal packing.
Details:
Patient was brought back to operative suite. Timeout was performed and all in agreement. Anesthesia was induced and patient intubated. Head of bed turned 90 degrees to right. Patient was prepped and draped in normal sterile fashion for sinus surgery. Left nasal packing removed. Two afrin soaked pledgets placed in nose and 1.5cc of lidocaine with 1:100,00 epi was injected into the nare. Bilateral nasal endoscopy performed and small amount of active bleeding noted on right anterior nasal septum but no active bleeding from left nare. No masses or tumors noted. Using 1 french suction bovi in setting of 8 right nasal septum was cauterized and small amount of silver nitrate used. Complete hemostasis achieved. Small piece of bacitracin soaked gelfoam placed in right nare and small piece of surgicel placed in left middle meatus. Both packing are dissolvable and do not have to be removed. Head of bed turned back to normal. Care of patient returned to anesthesia who extubated without complication. Taken to PACU in stable condition.