AN2114
Guru
The doctor did a drainage of right nasal abscess via transoral approach. Will this require an unlisted code or can I use code 40801? Or is there a better code that I'm just not finding? Any tips would be appreciated. Below is the op report:
Procedure: Drainage of right nasal abscess via transoral approach, needle aspiration of nasal abscess, nasal endoscopy, removal of nasal foreign body.
Details: The patient was brought to the operating room and general anesthetic was administered. She was intubated without complication. She right face was then prepped and the patient was draped in usually sterile fashion. First, a 0 degree endoscope was used to visualize the right nasal cavity. There was edema of the right lateral nasal wall along the superior aspect of the nasal cavity. There was edema of the right lateral nasal wall along the superior aspect of the inferior and middle turbinate. Afrin pledgets were then placed into the nose. A 22 gauge needle was then used to aspirate at the level of greatest fluctuance with return of minimal purulence. Pledgets were then re-placed into the right nasal cavity. Attention was then turned to the oral cavity. 2cc of 1% Lidocaine with 1:100,000 epinephrine was injected along the superior aspect of the teeth 6-8 at the level of the gingival ridge. A 15 blade was then used to make a 1.5 cm incision into the gingiva. Jake hemostat forceps were used to dissection in a subcutaneous plane towards the right nasal abscess. Careful palpation of the tips of the hemostats was done to ensure adequate dissection. The stats were introduced into the area of maximal fluctuance along the right nasal bone and any loculations were attempted to b e broken up. A 22 gauge needle was then injected transcutaneously into the area of greatest fluctuance and aspiration. Cultures were obtained at this point. The area of greatest fluctuance was palpated and was noted to be less edematous. Attention was then turned back to the nasal cavity. The 0 degree endoscope was then reintroduced. A foreign body measuring approximately 1.5 cm was visualized along the floor of the nasal cavity near the posterior aspect of the inferior turbinate. This was removed with hemostats and sent as specimen. The nasopharynx was then visualized and appeared grossly normal. Left sided nasal endoscopy was then performed and the nasal cavity appeared grossly normal. At this point, hemostasis was noted. The scope was removed. Care was then taken over by the anesthesia team and the patient was woken up without complication and taken to PACU in stable condition.
Procedure: Drainage of right nasal abscess via transoral approach, needle aspiration of nasal abscess, nasal endoscopy, removal of nasal foreign body.
Details: The patient was brought to the operating room and general anesthetic was administered. She was intubated without complication. She right face was then prepped and the patient was draped in usually sterile fashion. First, a 0 degree endoscope was used to visualize the right nasal cavity. There was edema of the right lateral nasal wall along the superior aspect of the nasal cavity. There was edema of the right lateral nasal wall along the superior aspect of the inferior and middle turbinate. Afrin pledgets were then placed into the nose. A 22 gauge needle was then used to aspirate at the level of greatest fluctuance with return of minimal purulence. Pledgets were then re-placed into the right nasal cavity. Attention was then turned to the oral cavity. 2cc of 1% Lidocaine with 1:100,000 epinephrine was injected along the superior aspect of the teeth 6-8 at the level of the gingival ridge. A 15 blade was then used to make a 1.5 cm incision into the gingiva. Jake hemostat forceps were used to dissection in a subcutaneous plane towards the right nasal abscess. Careful palpation of the tips of the hemostats was done to ensure adequate dissection. The stats were introduced into the area of maximal fluctuance along the right nasal bone and any loculations were attempted to b e broken up. A 22 gauge needle was then injected transcutaneously into the area of greatest fluctuance and aspiration. Cultures were obtained at this point. The area of greatest fluctuance was palpated and was noted to be less edematous. Attention was then turned back to the nasal cavity. The 0 degree endoscope was then reintroduced. A foreign body measuring approximately 1.5 cm was visualized along the floor of the nasal cavity near the posterior aspect of the inferior turbinate. This was removed with hemostats and sent as specimen. The nasopharynx was then visualized and appeared grossly normal. Left sided nasal endoscopy was then performed and the nasal cavity appeared grossly normal. At this point, hemostasis was noted. The scope was removed. Care was then taken over by the anesthesia team and the patient was woken up without complication and taken to PACU in stable condition.