Wiki suspension microlaryngoscopy with biopsy of right vocal cord lesion

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wynonna

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Hello,
Suspension microlaryngoscopy with biopsy of right vocal cord lesion
From body of note: A right sided cup forceps was used to grasp the superior free end and stripping of the mucosa was performed in the 2/3 of the anterior vocal cord which encompassed the vocal cord lesion.
The right vocal cord appeared to have an irregularity, which seems to be a contact ulcer, with an exophytic appearance to it as well.
Would this be CPT 31536, 31541, or 31545?
My first thought is 31541
thank you
 
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Good morning

Can you post the entire body of the operative report and any history/indications minus PHI? The header sounds like intent was a biopsy (31536), but the body of the note (the part that you snipped at least) sounds more like a stripping of the cord with total removal of the lesion along with the stripping (could support 31541). For 31545, you would need submucosal removal of a lesion (lifting up mucosa, identifying lesion below, and removing) plus reconstruction with local flaps. I don't see that level of work documented here, but I want to see if there are any additional details/clues that would definitively support one of these codes elsewhere in the note. If we can expand out a bit and get the rest of the body of the op note, I think that will help :).

Kim
 
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