mlh2000ku
New
I am not sure how I should be coding this? I was looking at code 21555? I am thinking there should be a more specific code for this? Below is the description: Any help would be greatly appreciated!!
We placed the trocars in the robotic and camera arms and then placed the 0 degree camera and both the retractor and the bovie cautery in the robotic arms. **Once we were in good position with the robot, I moved to the robotic console at the patients head. I first palpated the tumor and the infrrior aspest was at the superior aspect of the left tonsil and this extended into the soft palat on the left side. I marked out an incision with a marking pen form the superior tonsillar fossa into the left lateral soft palate. I then made the lateral tonsillar pillar incision and incised through the superior constrictors to expose the tumor. I developed a plane below the pharyngeal constrictor. *I elevated this plane medially and laterally around the tumor which was well encapulated. *Once I felt the superior, inferior, lateral and medial margins were exposed, I went to the head of the bed and performed blunt finger dissection of the posterior aspect of the tumor. The tumor ruptured anteriorly due to the pressure of dissection but I felt the capsule as well as the content of the tumor were removed in its entirety. We sent this to pathology for frozen section analysis. It was read a pleomorphic adenoma. We irrigated the wound with copious amounts of saline irrigation. I then brought the robot back in and placed the arms in good position. I used the robot to close the incision site with 3-0 vicryl suture in an interrupted pattern. Once the incision was closed, I backed the robot away.
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We placed the trocars in the robotic and camera arms and then placed the 0 degree camera and both the retractor and the bovie cautery in the robotic arms. **Once we were in good position with the robot, I moved to the robotic console at the patients head. I first palpated the tumor and the infrrior aspest was at the superior aspect of the left tonsil and this extended into the soft palat on the left side. I marked out an incision with a marking pen form the superior tonsillar fossa into the left lateral soft palate. I then made the lateral tonsillar pillar incision and incised through the superior constrictors to expose the tumor. I developed a plane below the pharyngeal constrictor. *I elevated this plane medially and laterally around the tumor which was well encapulated. *Once I felt the superior, inferior, lateral and medial margins were exposed, I went to the head of the bed and performed blunt finger dissection of the posterior aspect of the tumor. The tumor ruptured anteriorly due to the pressure of dissection but I felt the capsule as well as the content of the tumor were removed in its entirety. We sent this to pathology for frozen section analysis. It was read a pleomorphic adenoma. We irrigated the wound with copious amounts of saline irrigation. I then brought the robot back in and placed the arms in good position. I used the robot to close the incision site with 3-0 vicryl suture in an interrupted pattern. Once the incision was closed, I backed the robot away.
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