AN2114
Guru
I want an opinion on this report. Doctor did an endoscopic repair of right choanal atresia with posterior septectomy and outfracture of inferior turbinates. I have the whole report below and I have the cpt codes that I need. But the part about the septectomy is where I have a question, do I need to have the doctor go into more detail? Or can I still bill for the septectomy based on the small information given?
Patient was taken to surgery induced with general anesthesia and intubated. Shoulder roll was placed to provide neck extension. Patient was then properly prepped and draped. Image guidance with medtronic fusion system was set in place and noted to be working appropriately with the patient's CT scan. This was used throughout the procedure. Bilateral nasal endoscopy was performed using a 0 degree endoscope. On the left there was no pathology. On the right there was evidence of membranous and boney choanal atresia. Afrin and epi pledgets were used to decongest the nose and for hemostasis.
Using a navigation suction, the posterior nasopharynx was entered on the right side by popping through the obstructive tissue and then bone. A microdebrider and drill were used to further remove the obstructive tissue and bone and to widen the opening into the nasopharynx. A microbackbider was used to perform a posterior septectomy to further open the posterior nasopharynx. A boise elevator was used to outfracture and lateralize the inferior turbinates. A propel drug eluting stent was placed in the posterior choana/area of septectomy to stent this area open.
At this point the procedure was complete. Any additional bleeders that were encountered were controlled with afrin pledgets. All instrumentation was removed and patient was sent to recovery in satisfactory condition.
Patient was taken to surgery induced with general anesthesia and intubated. Shoulder roll was placed to provide neck extension. Patient was then properly prepped and draped. Image guidance with medtronic fusion system was set in place and noted to be working appropriately with the patient's CT scan. This was used throughout the procedure. Bilateral nasal endoscopy was performed using a 0 degree endoscope. On the left there was no pathology. On the right there was evidence of membranous and boney choanal atresia. Afrin and epi pledgets were used to decongest the nose and for hemostasis.
Using a navigation suction, the posterior nasopharynx was entered on the right side by popping through the obstructive tissue and then bone. A microdebrider and drill were used to further remove the obstructive tissue and bone and to widen the opening into the nasopharynx. A microbackbider was used to perform a posterior septectomy to further open the posterior nasopharynx. A boise elevator was used to outfracture and lateralize the inferior turbinates. A propel drug eluting stent was placed in the posterior choana/area of septectomy to stent this area open.
At this point the procedure was complete. Any additional bleeders that were encountered were controlled with afrin pledgets. All instrumentation was removed and patient was sent to recovery in satisfactory condition.
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