Wiki mass of tonsil

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PROCEDURE : Excision of mass, right tonsil

The patient was taken to operating room , under general endotracheal aneesthesia, was prepped and draped. The Croer -Davis mouth gag was inserted, and the oropharynx was visualized directly. The patient had a papillomatous mass of right tonsil. This was removed with sharp dissection. Hemostasis was achieved with electrocautry. The patient also had a tonsillith of left tonsil. This was removed with an alevator., A small amount of bleeding was controlled with suction cautery as well
 
I am thinking 42808 x2, one for the right and one for the left side. Any other thoughts?

Susan
 
I will have to agree with Susan...

UNLESS (I think this is very poor documentation by the way). Did the pathology report happen to indicate that the tonsils were removed completely or really just these lesions? I am having a hard time thinking/believeing that they just removed these lesions and not electing to just remove completely.

Also on the diagnosis....if the 795.4 what was printed on the pathology report and coded by them? If so, I would not use that. What exactly does the pathology report read for the diagnosis of the pathology submitted?

the not convinced
Mary, CPC, COSC
 
I agree with using the CPT code 42802 for the excisions. I would not use the path code 795.4 (Other nonspecific abnormal histological findings)
but instead would look at 235.1 Neoplasm of uncertain behavior pharynx or 474.9 . I agree that if possible it would be worth it to ask the doctor to elaborate on whether or not he performed a full tonsillectomy.

Evon, CPC
ENT
 
mbort said:
I will have to agree with Susan...

UNLESS (I think this is very poor documentation by the way). Did the pathology report happen to indicate that the tonsils were removed completely or really just these lesions? I am having a hard time thinking/believeing that they just removed these lesions and not electing to just remove completely.

Also on the diagnosis....if the 795.4 what was printed on the pathology report and coded by them? If so, I would not use that. What exactly does the pathology report read for the diagnosis of the pathology submitted?

the not convinced
Mary, CPC, COSC
Click to expand...


MARY,
Path report came back as dx 795.4 then also said beign cystic tonsillar crypt , i recheck my operative report and it is what i typed, yes I AGREE, vey poor dictation, BUT thanks everyone for their help. trent
 
I would use 210.5 then for the diagnosis. If possible I would still query the doctor to make sure the tonsils werent excised as all. If not then 42808 would be the code of choice.

Mary, CPC, COSC
 
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