Wiki 31541 or 31545 for surgery for hoarseness and dysphagia

[wynonna]

Hello.
Must 31545 include a reconstruction with local tissue flap. ie, if micro-flap was elevated encompassing the whole area of leukoplakia; so does this fit for 31545?
OR 31541 if no flap was done?
description of procedures: ( esophagoscopy, microlaryngoscopy and excision leukoplakia of right true vocal cord via microscissors)
Looking for CPT codes.

Thank you

 

[b.cobuzzi]

Wynonna, I am not sure what you are saying. Does the operative note say that a micro-flap was elevated encompassing the whole are of the leukoplakia? Or are you asking if that is what the op note needs to say for 31545? In order to qualify for 31545, there needs to be a local tissue flap that repairs the area where the leukoplakia is removed because the resection is so great, it cannot be left without reconstruction with some sort of tissue. 31545 indicates that a local flap is used while 31546 indicates that a free graft is used. The resections in 31545 and 31546 are significantly more than what you would find in 31541, where you do not need any reconstruction. That is the difference in the code sets. The description of "Operations performed" is not sufficient to determine what code is appropriate, without the body of the operative note. But, keep in mind that this forum is not a coding service.

Please indicate if you need more information. Thanks.