xefjao
Guest
hi fellow coders,
can someone out there help me to code this note:
i already have icd9-478.5 and cpt-31571
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Left vocal process granuloma
POSTOPERATIVE DIAGNOSIS: Left vocal process granuloma with polypoid degeneration of the vocal cords.
ANESTHESIA: General
OPERATIVE PROCEDURE: Suspension microlaryngoscopy, excision of vocal process granuloma, left side and injection of botulinum toxin type A 3.75 units.
INDICATIONS; A 54-year-old female with history of traumatic intubation developed hoarseness in the vocal process, has granuloma and is now admitted for removal as well as Botox injection. Risks of bleeding, infection, scarring, recurrence of the problem, persistence or worsening of his hoarseness, need for additional procedures have been discussed and all questions answered.
PROCEDURE N DETAIL: The patient was brought to the operating suite and under satisfactory general anesthesia with the Hunsakerjet ventilation tube and then the anterior commissure scope was inserted. The patient was placed on suspension. The epiglottis, AE folds and false cords were normal. The true cords inspected with 0-degree micro telescope. There was some polypoid degeneration of the cords. There was a small left vocal process granuloma with polypoid degeneration. The subglottis was normal. The vocal process granuloma, a small area of polypoid degeneration over the vocal processes was removed with the upbiting scissors. Bleeding controlled with adrenaline-soaked cottonoid 1:1000 once adequate hemostasis obtained, the left cord was injected with 1.5 cc of diluted Botox. A total of 3.75 units were placed. The patient tolerated this procedure well, was reversed from anesthesia and taken to recovery in stable condition.
thanks. hope to hear from anyone soon.
can someone out there help me to code this note:
i already have icd9-478.5 and cpt-31571
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Left vocal process granuloma
POSTOPERATIVE DIAGNOSIS: Left vocal process granuloma with polypoid degeneration of the vocal cords.
ANESTHESIA: General
OPERATIVE PROCEDURE: Suspension microlaryngoscopy, excision of vocal process granuloma, left side and injection of botulinum toxin type A 3.75 units.
INDICATIONS; A 54-year-old female with history of traumatic intubation developed hoarseness in the vocal process, has granuloma and is now admitted for removal as well as Botox injection. Risks of bleeding, infection, scarring, recurrence of the problem, persistence or worsening of his hoarseness, need for additional procedures have been discussed and all questions answered.
PROCEDURE N DETAIL: The patient was brought to the operating suite and under satisfactory general anesthesia with the Hunsakerjet ventilation tube and then the anterior commissure scope was inserted. The patient was placed on suspension. The epiglottis, AE folds and false cords were normal. The true cords inspected with 0-degree micro telescope. There was some polypoid degeneration of the cords. There was a small left vocal process granuloma with polypoid degeneration. The subglottis was normal. The vocal process granuloma, a small area of polypoid degeneration over the vocal processes was removed with the upbiting scissors. Bleeding controlled with adrenaline-soaked cottonoid 1:1000 once adequate hemostasis obtained, the left cord was injected with 1.5 cc of diluted Botox. A total of 3.75 units were placed. The patient tolerated this procedure well, was reversed from anesthesia and taken to recovery in stable condition.
thanks. hope to hear from anyone soon.