Posing this questions. Physician does a note and for the CC, he documents "Check up on vocal cords before my 3rd neck fusion". In the HPI, he notates "here for preoperative evaluation. The note ends with the assessment stating "Follow up" and under the ICD-9 he documents hearing loss unspecified and "preoperative evaluation of vocal cords". On top of that, he did a laryngoscopy but doesn't say why. My coworkers want to code the laryngoscopy and I say not to. They also want to code it as a consultation and I say it's a preop. Anyone care to respond with their thoughts?