AN2114
Guru
I would like an opinion on this op report. The doctor says he did a bilateral anterior/posterior ethmoidectomy and bilateral Sphenoidectomy but there isn't much of a description about those two procedures. Here is the op note:
The sterotactic navigation system was set up and calibrated accurately with known anatomical landmarks. A Zero Degree endoscope was inserted in the left nasal passage. Diffuse polyps were visualized in the left nare. The XPS was used on setting of 5,000 oxsillate to remove all polypoid tissue within the middle meatus, frontal sinus outflow tract, ethmoid and sphenoid regions. Care was taken not to violate the cribiform plate or lamina prapricia. A maxillary antrostomy was performed and tissue removed. Attention was then turned to the right side where the same procedure was performed. Once all obstructive tissue was removed a propel stend was placed in the bilateral ethomoid and maxillary sinus's. Floseal was administered into the bilateral nares and a mustache dressing was placed. Care of patient returned to the anesthesia team.
I feel like this may not be enough info to code for an ethmoidectomy and sphenoidectomy (and usually in the op reports when they do those procedures do provide more information). Does anyone think that is enough info to code for those procedures?
The sterotactic navigation system was set up and calibrated accurately with known anatomical landmarks. A Zero Degree endoscope was inserted in the left nasal passage. Diffuse polyps were visualized in the left nare. The XPS was used on setting of 5,000 oxsillate to remove all polypoid tissue within the middle meatus, frontal sinus outflow tract, ethmoid and sphenoid regions. Care was taken not to violate the cribiform plate or lamina prapricia. A maxillary antrostomy was performed and tissue removed. Attention was then turned to the right side where the same procedure was performed. Once all obstructive tissue was removed a propel stend was placed in the bilateral ethomoid and maxillary sinus's. Floseal was administered into the bilateral nares and a mustache dressing was placed. Care of patient returned to the anesthesia team.
I feel like this may not be enough info to code for an ethmoidectomy and sphenoidectomy (and usually in the op reports when they do those procedures do provide more information). Does anyone think that is enough info to code for those procedures?