Hello,
I need confirmation for the following 2 notes. How would you code for the notes below? On example 1 CPT code 31599
EXAMPLE 1
Pt with recurrent papillomas causing dysphonia. Preoperatively, the patient was counseled on the options and has chosen to undergo a laser office procedure to ablate the lesions.
Operative Procedure: The patient was brought to the procedure room and identified by myself.* The patient was then placed in the procedure chair and topical anesthetic and vasoconstrictive agents were instilled into the nasal cavity.* After adequate time, a laryngoscope with a side channel was introduced through the nasal cavity and positioned in the pharynx over the laryngeal inlet.* Then, 4% lidocaine was dribbled into the laryngeal inlet while the patient was phonating to allow the vocal folds to become anesthetized.* The endoscope was then removed and adequate time was given for the patient's anesthesia to take effect.* Next, a flexible endoscope with a side channel was introduced into the nasal cavity again and passed into the pharynx.* The larynx was then visualized.* A 0.4-mm laser fiber was then passed through the side channel of the laryngoscope and the tip was visualized on the monitor.* Its magnified view allowed proper aiming of the laser* beam at the vocal fold lesions.* The KTP laser was set at* 22 watts with a 22-msec pulse with 2 pulses per second.* Laser energy was delivered to the bilateral vocal fold lesions in contact mode.* A total of 99 Joules of energy was delivered.* Overall, the patient tolerated the procedure well.* The endoscope was then removed along with the laser.* The patient was sent home in stable condition.
EXAMPLE 2 -
Magnified laryngoscopy with vocal cord injection augmentation
Indications:* The patient has progressive hoarseness related to vocal fold paralysis.* Pt has inability to communicate effectively, affecting the patient's quality of life.
Description of Operative Procedure: The patient was brought to the procedure room and identified by myself.* The patient was then placed in the procedure chair and topical anesthetic was sprayed into his nasal cavity along with a vasoconstrictive agent.* Additional anesthetic was injected into the neck skin overlying the thyroid notch.* A flexible endoscope was then passed through the nasal cavity, and the larynx was visualized.* Topical anesthesia was then delivered through the thyrohyoid membrane using a #25-gauge needle and dribbling 4% lidocaine onto the larynx.* The needle and the endoscope were removed.* After adequate time, the endoscope was reintroduced into the nasal cavity, and a magnified view of the larynx was obtained.* A #25-gauge needle was then inserted through the thyrohyoid membrane and angled to reach the right vocal fold.* Calcium Hydroxyapetite was then injected into the right vocal fold.* A total of 0.9 cc was injected. The patient tolerated the procedure well and was discharged in stable condition.
I need confirmation for the following 2 notes. How would you code for the notes below? On example 1 CPT code 31599
EXAMPLE 1
Pt with recurrent papillomas causing dysphonia. Preoperatively, the patient was counseled on the options and has chosen to undergo a laser office procedure to ablate the lesions.
Operative Procedure: The patient was brought to the procedure room and identified by myself.* The patient was then placed in the procedure chair and topical anesthetic and vasoconstrictive agents were instilled into the nasal cavity.* After adequate time, a laryngoscope with a side channel was introduced through the nasal cavity and positioned in the pharynx over the laryngeal inlet.* Then, 4% lidocaine was dribbled into the laryngeal inlet while the patient was phonating to allow the vocal folds to become anesthetized.* The endoscope was then removed and adequate time was given for the patient's anesthesia to take effect.* Next, a flexible endoscope with a side channel was introduced into the nasal cavity again and passed into the pharynx.* The larynx was then visualized.* A 0.4-mm laser fiber was then passed through the side channel of the laryngoscope and the tip was visualized on the monitor.* Its magnified view allowed proper aiming of the laser* beam at the vocal fold lesions.* The KTP laser was set at* 22 watts with a 22-msec pulse with 2 pulses per second.* Laser energy was delivered to the bilateral vocal fold lesions in contact mode.* A total of 99 Joules of energy was delivered.* Overall, the patient tolerated the procedure well.* The endoscope was then removed along with the laser.* The patient was sent home in stable condition.
EXAMPLE 2 -
Magnified laryngoscopy with vocal cord injection augmentation
Indications:* The patient has progressive hoarseness related to vocal fold paralysis.* Pt has inability to communicate effectively, affecting the patient's quality of life.
Description of Operative Procedure: The patient was brought to the procedure room and identified by myself.* The patient was then placed in the procedure chair and topical anesthetic was sprayed into his nasal cavity along with a vasoconstrictive agent.* Additional anesthetic was injected into the neck skin overlying the thyroid notch.* A flexible endoscope was then passed through the nasal cavity, and the larynx was visualized.* Topical anesthesia was then delivered through the thyrohyoid membrane using a #25-gauge needle and dribbling 4% lidocaine onto the larynx.* The needle and the endoscope were removed.* After adequate time, the endoscope was reintroduced into the nasal cavity, and a magnified view of the larynx was obtained.* A #25-gauge needle was then inserted through the thyrohyoid membrane and angled to reach the right vocal fold.* Calcium Hydroxyapetite was then injected into the right vocal fold.* A total of 0.9 cc was injected. The patient tolerated the procedure well and was discharged in stable condition.