Panendoscopy with biopsies & Tonsillectomy

rgeib

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So I'm not 100% confident in my CPT codes for this op report:

PREOPERATIVE DIAGNOSIS: Metastatic squamous cell carcinoma to the
lymph node, right neck, unknown primary.

ANESTHESIA: General endotracheal anesthesia.

PROCEDURES PERFORMED:
Panendoscopy with biopsies (rigid bronchoscopy, rigid laryngoscopy,
rigid nasopharyngoscopy, rigid oropharyngoscopy, rigid esophagoscopy
aborted due to anatomy). Other procedures included right
tonsillectomy, biopsies of the right base of tongue, and right
nasopharynx.

IV FLUIDS:
Received 1400 mL lactated Ringer's, clindamycin 600 mg, and Tylenol
1 g.

EBL:
Minimal.
SPECIMENS:
Sent to pathology included right tonsil, right base of tongue,
right nasopharynx, right lateral oropharyngeal hypopharyngeal area.

INDICATIONS:
This is a male with history of a 5 cm right neck mass
with fine-needle aspirate done in the office consistent with
findings of metastatic squamous cell carcinoma. He has had a PET/CT
scan, which revealed increased activity in the right level 2, 3
lymph node basin, large 4+ cm mass. MRI scan and CT scans likewise
showed this mass. No other significant lymphadenopathy was found
nor any other increased activity abnormality. He was taken to the
operating room for diagnostic studies to determine etiology of the
metastatic cancer.

FINDINGS AT TIME OF SURGERY:
The right tonsil had firmness measuring approximately 1.5 to 2 cm
at its inferior deep aspect with removal of this. It had a fibrotic
appearance to it. Questionable malignant appearance. The rest of
the examination was normal including nasal cavity bilateral,
nasopharynx bilateral, oral cavity, oropharynx, hypopharynx, larynx,
mainstem trachea, and mainstem bronchi. The esophagoscopy could not
be performed because of an anterior located esophagus per venting
rigid esophagoscopy from being done. No mass was seen however.

DESCRIPTION OF OPERATION:
Procedure as follows; after adequate preoperative counseling and
consent had been obtained, the patient was taken to the operating
room, IV lines monitors placed per Anesthesia and general
endotracheal anesthesia administered. The patient was given
medicines per Anesthesia. He was turned 90 degrees away from
Anesthesiology and shoulder roll placed and he was draped in usual
fashion. Time-out was taken by the operating team to confirm the
patient identification, procedure, and site. A visual examination
of the oral cavity and oropharynx was performed as well as bimanual
palpation of the oral cavity, tongue, floor of mouth, and neck.
Findings revealed a 5 cm firm, hard, fixed mass in the right level
2, 3 neck. This was 5 x 3 cm. The next portion of the procedure
included putting a dental bite guard over his upper teeth. These
teeth were noted to be in good condition. Minimal decay. Rigid
laryngoscopy
was performed and noted to have normal oral cavity,
pharynx, hypopharynx, and larynx. No mass was visible. No
asymmetry. There is no palpable right base of tonsil firmness. No
exophytic lesion was seen. A rigid bronchoscopy was then performed.
The balloon cuff was let down on the endotracheal tube as the rigid
bronchoscope was passed over this into the trachea down to the
carina and mainstem bronchi. No pathology was noted on entrance nor
exit. Rigid esophagoscopy was then attempted. He was noted to have
normal piriform sinuses, but the entrance into the esophagus was
anteriorly located and with the patient anatomy was not able to pass
the rigid endoscope into this opening without causing trauma and
therefore this was aborted.
No mass was seen though at the entrance
of the esophagus. A rigid nasal endoscopy was then performed after
nasal cavity had been packed with cottonoid pledgets soaked in
Neo-Synephrine lidocaine for over 10 minutes. Removal of the
packing pledgets and passage of the rigid nasal endoscope revealed
normal nasal cavity and nasopharynx. Biopsy was taken of the right
lateral nasopharynx
with Tru-Cut forceps and this bleeding was
controlled with a suction Bovie cautery. Then, the patient was
prepared for doing tonsillectomy using a mouth gag and suspension
apparatus. The patient was suspended on the Mayo tray, and the
right tonsil capsule was injected with 0.5% Marcaine, 2 mL thereof
and the superior tonsillar pole was incised after the tonsil was
retracted medially with curved tonsil clamps and the peritonsillar
capsule was entered and dissection continued from superior to
inferior direction obtaining hemostasis in the process.
In the
inferior aspect, he was noted to have a firm fibrotic appearing
submucosal tissue that was partially removed with the removal of the
tonsil. Tonsil sponge soaked in 0.5% Marcaine and tannic acid was
placed in the tonsil fossa for 3 minutes and then removed. Good
hemostasis confirmed. Further biopsy of this inferior most aspect
of the tonsillar pole was done and sent for frozen pathology
, which
did not show any malignant tissue. Further bimanual palpation of
this area revealed a slight firmness residual in this inferior
aspect of the tonsillar pole extending down to the vallecula.
Biopsies of the right posterior lateral base of tongue in this area
was done for ruling out any extension into this area.
No visible or
palpable pathology was found however. At this time, procedure was
complete and orogastric tube was able to be placed and suctioning of
the stomach revealed clear secretions. The mouth gag was removed
and the dental bite guard was removed and the patient was turned
back to Anesthesia, allowed to awaken, was extubated, and taken to
the recovery room in stable condition. We will await final
pathology report for determination of whether source of his
metastatic disease was found. Plan will be to have him be seen by
radiation oncology and medical oncology for potential chemotherapy
and radiation therapy. A surgical salvage for any residual neck
disease would be performed if necessary in the future.

So the best I've come up with is:

42826 for Tonsillectomy

31535-59 for rigid laryngoscopy w/ tongue & tonsil biopsies (mod-59 added to break bundle with 31622. This particular insurance has been known to accept this unbundling in the past)

43191-53 for rigid esophagoscopy (mod-53 added as notes show procedure was d/c'd)

31622 for rigid bronchoscopy

31237 for rigid nasopharyngoscopy with biopsy of nasopharynx:

Any input would be appreciated. This one has been stumping me for an entire afternoon. Thanks.
 

JenniferB7

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Local Chapter Officer
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You are close!

I would code it as follows:

  • 31237 (RVU: 6.94) - Nasal Endoscopy with Biopsy
  • 42826 (RVU: 6.92) - Tonsillectomy (includes tonsil biopsy)
  • 31525-59 (RVU: 6.83) - Rigid laryngoscopy; diagnostic, except newborn
  • 31622 (RVU: 6.52) - Diagnostic Rigid Bronchoscopy
  • 41105 (RVU: 4.67) - Base of Tongue Biopsy
  • 43191-53 (RVU 4.29) - Rigid esophagoscopy, diagnostic

The tonsil biopsy is included in the tonsillectomy. You cannot bill for both an excision and biopsy of the same area. It is one or the other.

Also, there is no indication that the biopsy was done as part of the laryngoscopy. The laryngoscope had been removed prior to the base of tongue biopsy, which was performed after the tonsillectomy. Therefore, you bill the tongue biopsy as an open excision, 41105.

Hope that helps!
 

rgeib

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Thanks, Jennifer. This was extremely helpful in clearing up the areas I was stuck on.
 
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