Wiki Micro direct laryngoscopy with removal of polypoid mass from bilateral vocal cords

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wynonna

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Hinsdale, MA
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"Visualization with a lighted laryngoscope was performed. A tooth guard was used over her upper alveolar ridge to protect it. There were polypoid lesions emanating from both anterior vocal cords that were obstructing the anterior airway. These were carefully removed using an alligator forcep to grasp them and laryngeal scissors or cup forceps to excise. The specimens were sent independently for pathology review. Intermittently Neo-Synephrine saturated cottonoids were used for hemostasis. The remainder of the larynx and pharynx were inspected with the laryngoscope including the piriforms, vallecula, base of tongue, lateral pharyngeal wall and epiglottis and no suspicious lesions were noted in these areas. Examination of the posterior glottis confirm no obstructing airway in that region. The immediate upper trachea was clear. The airway was markedly improved at the conclusion of the procedure."

What would the CPT's be?
 
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Just in case you didn't know, you can't code from the header of the note. So if the header says the surgery performed was a "micro-direct laryngoscopy with removal of mass", you need to look for the reference in the BODY of the op note that a microscope was used . See below for the difference. I don't see that anywhere in what you posted, unless you left out some of the body of the op note. What you posted from the op note sounds like a regular DL with removal of mass, not a MDL with removal of a mass.
31540: Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis;
31541: Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope
 
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