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Can I get help coding this op note.

S

sutherngyrl

Contributor
Messages
18
Location
Beaufort, SC
CO2 laser was brought into the field and connected to the microscope. The patient's eyes were protected with moist eye pads and face was protected with towels. Saline was placed in the cuffs and saline pledgets placed over the cuffs. All personnel in the room wore laser wavelength specific eyewear. FiO2 was 30%.
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The right supraglottic mucosa was incised with the laser just inferior to the AE fold on the right. This line was extended the length of the AEF. Dissecting with the laser laterally, we encountered an epithelial lined air pocket, consistent with the laryngocele. We continued dissection to encompass the right false fold, protecting the true fold with a saline pledget. The right false fold was removed. The majority of the epithelium of the laryngocele was removed but there was a small amount of lateral-superior in situ epithelium. We defocused the laser and ablated this mucosa completely.
 
Is there more to the operative report. I cannot tell from what you have provided if the provider used a rigid or flexible laryngoscope with the CO2 laser and microscope. I need that information to better assist you.
 
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