abyrne
Networker
Hi all - new to ENT coding and need some help. Doctor is trying to bill CPT 61605 for the following, but we aren't sure that's correct. Any thoughts would be greatly appreaciated!
Pre-op diagnosis: Parapharyngeal space mass
Path confirmed: Benign Neoplasm Salivary Gland
Procedure Description:
Patient was brought to the room and identified by name and clinic number. General endotracheal anesthesia was induced by the anesthesia service. Patient was placed in a supine position in standard fashion for neck surgery. The neck was prepped and draped in the standard sterile fashion. 1% lidocaine with epi 1 100,000 was injected. Nerve monitor was in place monitoring the marginal mandibular branch of the facial nerve. Incision was made and taken down to the subplatysmal plane. Superior flap was raised over the mandible. The marginal mandibular nerve was identified fully preserved and dissected. I then separated the tails of parotid gland from the sternocleidomastoid muscle in the posterior belly of the gastric muscle was identified and isolated. The submandibular gland was retracted anteriorly. The external carotid artery was ligated and the the pterygomandibular ligament was removed to enter the parapharyngeal space. Immediately noted was a large mass within this space. Blunt dissection was carried around the anterior aspect of the mass. I then dissected it from the undersurface of the mandible and away from the attachments to the deep parotid gland. It was immediately adjacent to the styloid process and the styloid process was preventing adequate dissection of this area. I then isolated the styloid process completely removed at the rongeur. Continued dissection was then performed and the mass was completely removed from neck. Small fenestration of the capsule was noted but no leakage of tumor was found. It was also noted that the dissection was near the marginal branch of the facial nerve but was completely visualized during the dissection and was stimulating after dissection was completed.
A drain was then placed and incision was closed in layers. Patient was turned over to anesthesia for wake-up and recovery and was taken to the PACU in stable condition.
Pre-op diagnosis: Parapharyngeal space mass
Path confirmed: Benign Neoplasm Salivary Gland
Procedure Description:
Patient was brought to the room and identified by name and clinic number. General endotracheal anesthesia was induced by the anesthesia service. Patient was placed in a supine position in standard fashion for neck surgery. The neck was prepped and draped in the standard sterile fashion. 1% lidocaine with epi 1 100,000 was injected. Nerve monitor was in place monitoring the marginal mandibular branch of the facial nerve. Incision was made and taken down to the subplatysmal plane. Superior flap was raised over the mandible. The marginal mandibular nerve was identified fully preserved and dissected. I then separated the tails of parotid gland from the sternocleidomastoid muscle in the posterior belly of the gastric muscle was identified and isolated. The submandibular gland was retracted anteriorly. The external carotid artery was ligated and the the pterygomandibular ligament was removed to enter the parapharyngeal space. Immediately noted was a large mass within this space. Blunt dissection was carried around the anterior aspect of the mass. I then dissected it from the undersurface of the mandible and away from the attachments to the deep parotid gland. It was immediately adjacent to the styloid process and the styloid process was preventing adequate dissection of this area. I then isolated the styloid process completely removed at the rongeur. Continued dissection was then performed and the mass was completely removed from neck. Small fenestration of the capsule was noted but no leakage of tumor was found. It was also noted that the dissection was near the marginal branch of the facial nerve but was completely visualized during the dissection and was stimulating after dissection was completed.
A drain was then placed and incision was closed in layers. Patient was turned over to anesthesia for wake-up and recovery and was taken to the PACU in stable condition.