Question CPT for Laryngoscopy and biopsy left base of tongue, vallecula

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wynonna

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CPT for Direct Laryngoscopy and biopsy left base of tongue, vallecula with general anesthesia.
Procedure began with using a lighted laryngoscope suspended and exam bimanually of base of tongue. There was a prominence in the extending into the vallecula. Overlying mucosa was normal.
MD took biopsies with a cup forcep in the area of the left base of tongue, laterally, sent to pathology.
So my question to fellow ENT, does a 31535 cover MD work?
Or do I also bill a 42800 for Biopsy of oropharynx or 42804 bx of nasopharynx?
thank you so much!
 
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Keep in mind that it sometimes difficult to determine if the biopsy is performed via the endoscope or open and the endoscope is used for localization only because of unclear documentation. Whenever you are unsure, Query the surgeon.
 
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b.cobuzzi said:
Sounds like 41105, biopsy of tongue, posterior one third plus a diagnostic laryngoscopy 31525. It does not sound like the tongue biopsy was taken via endo
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Hi Barbara,

What about this op-report? Dr does a biopsy of the base of the tongue with a flexible laryngoscope. No exam of the larynx noted. Would this documentation support 31576 as indicated as the billing code from the physician.

OPERATION: Flexible fiberoptic laryngoscopy with biopsy of left base of tongue lesion

INDICATIONS: This patient is an 80 y/o male with history CLL and mantle cell lymphoma, who presented with evidence of left sided base of tongue lesion. The patient was consented for a flexible fiberoptic laryngoscopy with biopsy of the mass to obtain a pathologic diagnosis. He understands the risks which include, but are not limited to infection, bleeding, possible regrowth, and the need further surgery.

PROCEDURE IN DETAIL: The patient was brought into the procedure room and placed partially supine un the procedure room table. The patient was draped in the usual fashion for minimally invasive procedures. Pledgets soaked in Afrin and 4% topical lidocaine solution were placed within the nasal cavity for decongestion. After approximately 8-10 minutes of allowing for optimal decongestion, the pledgets were removed. The flexible fiberoptic rhinolaryngoscope with the operating port was inserted into the nasal cavity, which was examined-normal anatomy and mucosa throughout. A solution of 4% topical lidocaine was intermittently sprayed throughout the passage of the rhinolaryngoscope down into the glottis to ensure maximal anesthetic effect. Once the left base of tongue lesion was localized, a rhinolaryngoscope paired cup forcep instrument was passed through the operating port and utilized to take multiple biopsies of the left base of tongue lesion. Specimens were passed to procedure staff to send to pathology. The biopsy site was examined for hemostasis, which was satisfactory. At this time the rhinolaryngoscope was fully removed from the patient and the procedure completed. He was brought, without complication, to the recovery room.

PATHOLOGY:
A Tongue, Base of Tongue for Lymphoma Protocol
B Tongue, Base of Tongue
Clinical Information
Admission Diagnosis: Malignant neoplasm of base of tongue CO1
Pre-op Diagnosis: Malignant neoplasm, base of tongue
Fresh for Lymphoma Protocol

Procedure: Flexible laryngoscopy and biopsy- base of tongue

Final Diagnosis
A. Base of tongue, biopsy for flow cytometry:
-No immunophenotypic features of clonal B-cell population.
-Markedly increased CD4 to CDS ratio noted in T-cells (see separate flow cytometry report).

B. Base of tongue, biopsy
-Focally ulcerated squamous mucosa with underlying lymphoid infiltrate, favor reactive, see comment.


Thank you!
 
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