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a Sinus surgery-Help!

Jennercoder

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Hello Everyone: I am working w/o an Encoder- please help! I don't think this report supports a 31287. (?) Some parts are abbreviated, the surgical left in.

Pre Op dx: Posterior Left ethmoid, sphenoid polyp, Left nose
Post Op Dx: Same
Procedure: Endoscopic L Ethmoid and sphenois sinusotomy and polypectomy

Description of procedure: > induct. of gen. anesthesia, the propped, etc.

.... "Complete endoscopic examination was carried out with the findings of considerable polypoid material in Left posterior ethmoid at the attachment of the turbinate.

The Rigth naris was clear . Under 0 degree emdoscope control, a specimen was sent from the large polypoid mass of the left posterior nares.

In using the Gyrus power debrider, the L posterior extensive polypectomy carried out to the sphenoid sinus, sparing the lamine and base of skull. The sphenoid sinus was NOT entered.

Hemostasis acheived, using cautery etc, etc.
 
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