Wiki Coding for Exploratory removal of Stone


Bristol, PA
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I think I should code this as exploratory because the actual code that this procedure was scheduled with was not actually done. The dr put this on as 42335 here is the op report. Can someone give me some feedback if this should be exploratory and what code to use?

PREOPERATIVE DIAGNOSIS: Sialolithiasis, left submandibular gland duct.
POSTOPERATIVE DIAGNOSIS: Sialolithiasis, left submandibular gland duct.
PROCEDURE: Attempted removal of stone, left submandibular gland duct.
ANESTHESIA: General with local Xylocaine.

PROCEDURE DESCRIPTION: This is a 9-year-old with a stone in the left submandibular gland duct, palpable and visible just at the area of the orifice of the duct. The patient has had recurrent swelling of the gland.

The patient was correctly identified in the supine position. General anesthesia was induced, and a timeout was performed. Mouth gag was placed. The tongue was elevated. The stone was grasped with a Brown-Adson forceps, an incision made to the mucosa overlying the stone, and the stone immediately popped back into the duct. It was not visible or palpable. The duct was gently probed. Decision was made not to extend the incision into the floor of the mouth looking for the stone for the fear of causing damage and still being unable to remove the stone. Palpation of the neck did not reveal the stone expressed toward the floor of the mouth, and the procedure was then terminated.

He was extubated, transferred to the recovery room in stable condition after local anesthesia was injected into the floor of the mouth.