Balloon Sinuplasty Again

NESmith

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Good Morning. I am really new in coding ENT and I need help with an Op-Report.

Following signing of the consent, the patient was brought into the examination room and placed in the ENT chair in a reclining position. the nasal cavities were sprayed with 4% topical lidocaine and oxymetazoline. Pledgets soaked in 2% tetracaine and oxymetazoline were introduced into the bilateral middle meatus, between the septum and middle turbiante, and the inferior margin of the middle turbinate. The pledgets were left in place for 20 minutes and removed. 1% lidocaine and 1:100,000 units of epinephrine, 2cc, was infiltrated into the superior attachment of the middle turbinate, the uncinate process, and the inferior margin of the middle turbinate. the camera, attached to the 0 degree, 3.7 mm nasal endoscope, was introduced into the left nasal cavity. The Freer elevator was used to medialize the middle turbinate. The lighted frontal sinus seeker was advanced atraumatically into the frontal sinus and confirmed via transillumination on the forehead. The balloon sinuplasty cather was placed medical to the uncinate process and directed toward the frontal sinus recess. the balloon was advanced without resistance into the frontal sinus and inflated. the patient tolerated the inflation without complication. The balloon catheter was removed. I then moblilized the uncianate process, anteriorly, using the maxillary sinus seeker. the balloon wand was gently bent using the Rabbit. the balloon catheter was introduced into the semilunaris. The balloon was advanced to a position to enlarge the ostium and mobilize the uncinate process anteriorly. The balloon was inflated. the patient tolerated the inflation wothout complication. the Freer elevator was used to lateralize the middle turbinate and the endoscope was used to identify the sphenoid ostium. the balloon was advanced easily into the sinus. the balloon was inflated and the patient tolerated the procedure wothout complication. the exact procedure was performed on the contralateral side with the exception of the right sphhenoid sinus. Upon completion of all procedures, the patient had no complaints. Suctioning was done and the pledgets were replaced for hemostasis and later removed. All counts were correct. Post operative instructions, prescriptions, gauze pads and a return appointment was provided.

Procedure billed as follow:
31295-dx 473.0
31296-dx 473.1
31297-dx 473.3, 473.1, 473.0, 473.2
POS-11
After review, please advise.
Thank You as always for everyones help
 

Lujanwj

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Doesn't sound like Dr took any tissue so your codes are good with the exception of the -50. Dr stated "the exact procedure was performed on the contralateral side with the exception of the right sphenoid sinus".

31296-50
31295-50
31297
 
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