Capelo
New
Hello,
Provider wants to code a 31630 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial dilation or closed reduction of fracture) and I believe it should be 31899 based on the documentation which doesn't state a scope was used, what do you think? Provider did state it was a balloon dilator catheter (not attached to a scope) which was used for the dilation and that it's similar to using a rigid scope, more of a hybrid technique?
The patient is a gentleman with a history of laryngectomy with the stoma, which is narrowed from 1.5 cm down to approximately 7 mm. At this time, presents for dilation of this with an atraumatic balloon dilation technique.
The patient was brought to the OR after general anesthesia was established. The tracheal narrowing at the level of the stoma was dilated with a balloon dilator initially to 10 mm, then 11, then 12. Once the dilation was completed, a laryngectomy tube was placed into the area of the lumen and secured both with stay ties as well as sutures and the patient had a Xeroform placed superiorly and inferiorly to prevent any soft tissue injury from the laryngectomy tube itself. The patient will be seen in one week's postoperative time to make sure that there is no evidence of any soft tissue issues related to the laryngectomy tube itself. The area appeared to be well dilated with no evidence of any tissue injury or bleeding. The patient's family and the patient were advised if there are any airway symptoms, bleeding or other issues, he should return immediately to the Emergency Room for management. The patient after awakening was transferred to recovery room in stable condition.
Thank you for any assistance you may be able to provide.
Provider wants to code a 31630 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial dilation or closed reduction of fracture) and I believe it should be 31899 based on the documentation which doesn't state a scope was used, what do you think? Provider did state it was a balloon dilator catheter (not attached to a scope) which was used for the dilation and that it's similar to using a rigid scope, more of a hybrid technique?
The patient is a gentleman with a history of laryngectomy with the stoma, which is narrowed from 1.5 cm down to approximately 7 mm. At this time, presents for dilation of this with an atraumatic balloon dilation technique.
The patient was brought to the OR after general anesthesia was established. The tracheal narrowing at the level of the stoma was dilated with a balloon dilator initially to 10 mm, then 11, then 12. Once the dilation was completed, a laryngectomy tube was placed into the area of the lumen and secured both with stay ties as well as sutures and the patient had a Xeroform placed superiorly and inferiorly to prevent any soft tissue injury from the laryngectomy tube itself. The patient will be seen in one week's postoperative time to make sure that there is no evidence of any soft tissue issues related to the laryngectomy tube itself. The area appeared to be well dilated with no evidence of any tissue injury or bleeding. The patient's family and the patient were advised if there are any airway symptoms, bleeding or other issues, he should return immediately to the Emergency Room for management. The patient after awakening was transferred to recovery room in stable condition.
Thank you for any assistance you may be able to provide.