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Otolaryngology Coding Alert

Reader Questions:

42800 Portrays Biopsy Without A Scope

Published on Tue Mar 08, 2011

Question: I need help in coding the following physician's report. What CPT and ICD-9 code would be appropriate?NAME OF OPERATION: Biopsy left tonsil with frozen section.PREOPERATIVE DIAGNOSIS: Left tonsil lesion, probable carcinoma.POSTOPERATIVE DIAGNOSIS: Left tonsil lesion, benign.FINDINGS: It was edematous inferior pole of the left tonsil. It also was moderately indurated. There was no evidence of an exophytic lesion nor any erosion. There were no palpable lymph nodes in the neck.PROCEDURE: The patient was placed under general anesthesia and after orotracheal intubation, the self retaining mouth gag was inserted in the mouth and anchored to the Mayo stand. The left tonsil and right tonsil were palpated and examined visually. There was some induration in the inferior pole of the left tonsil and it appeared more edematous than the right. We used a punch biopsy to take two biopsies of the indurated area and sent them for frozen section. Bleeding was [...]
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