Wiki suspension microlaryngoscopy with biopsy of right vocal cord lesion

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
 
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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