I'm having difficulties coding the different scopes my doctors utilizes. Please, help. The following is the most recent op note I have been given to code.
Procedures:
1. Direct larynoscopy
2. Telescopic direct laryngoscopy
3. Telescopic bronchoscopy
4. Esophagoscopy
5. Micro direct laryngoscopy with bilateral true vocal cord biopsies
Findings: The patient had polypoid lesion of the right mid true vocal cord and leukoplakia involving the lest mid true vocal cord.
Operation: The patient was placed in a supine position. General anesthesia was induced. He was draped in normal sterile fashion. Direct laryngoscopy was performed. No lesions were noted of the base of tongue, valleculs, epiglottis, posterior or lateral pharyngeal walls. The laryngeal area was sprinkled w/ 1% plain Xylocaine. The telescopic laryngoscopy was performed, and the above noted lesions were identified. Telescopic bronchoscopy was performed. There was no evidence of subglottic lesion. Tracheal arches were easily visualized. There was no edema, erythemia or cobblestoning. The patient was then intubated by myself. Cervical esophagoscopy was performed without difficulty. No lesions were identified. Then suspension laryngoscopy was performed with a Dedo scope and microscope visualization was carried out to identify the above-described lesions. The polypoid lesion of the right true vocal cord was biopsied and removed. The leukoplakia of the left true vocal cord was also biopsied. The patient tolerated procedure well and was awakened and transferred to recovery room in good condition.
My initial coding is as follows:
31526, 31541(RT) and 31536 (LT)
Procedures:
1. Direct larynoscopy
2. Telescopic direct laryngoscopy
3. Telescopic bronchoscopy
4. Esophagoscopy
5. Micro direct laryngoscopy with bilateral true vocal cord biopsies
Findings: The patient had polypoid lesion of the right mid true vocal cord and leukoplakia involving the lest mid true vocal cord.
Operation: The patient was placed in a supine position. General anesthesia was induced. He was draped in normal sterile fashion. Direct laryngoscopy was performed. No lesions were noted of the base of tongue, valleculs, epiglottis, posterior or lateral pharyngeal walls. The laryngeal area was sprinkled w/ 1% plain Xylocaine. The telescopic laryngoscopy was performed, and the above noted lesions were identified. Telescopic bronchoscopy was performed. There was no evidence of subglottic lesion. Tracheal arches were easily visualized. There was no edema, erythemia or cobblestoning. The patient was then intubated by myself. Cervical esophagoscopy was performed without difficulty. No lesions were identified. Then suspension laryngoscopy was performed with a Dedo scope and microscope visualization was carried out to identify the above-described lesions. The polypoid lesion of the right true vocal cord was biopsied and removed. The leukoplakia of the left true vocal cord was also biopsied. The patient tolerated procedure well and was awakened and transferred to recovery room in good condition.
My initial coding is as follows:
31526, 31541(RT) and 31536 (LT)