LaceyCanon
Networker
Can someone help with CPT code for the following:
After informed consent was given, risks, benefits and alternatives were discussed with the patient, patient was brought to the operating room and anaesthetized by Department of General Anesthesia. Once this was done, time-out was called correctly confirming the patient and procedure. Afrin pledgets were then placed into the nose, the patient was prepped and draped in usual sterile fashion. The right nasal cavity was then examined first with a 0-degree telescope, 1% lidocaine with 1:100,000 epinephrine was injected along the middle turbinate in the lateral wall. This injection was done similarly on the left side. The right nasal cavity was examined first. There was synechiae band noted between middle turbinate and lateral nasal wall, this was divided with straight scissors and middle turbinate was then medialized with freer elevator. The 30-degree scope was used to examine the right maxillary sinus and photos were taken. There was some minimal disease noted in the floor of the maxillary sinuses otherwise clear at this time. Irrigation was used to irrigate after sinus. Next, the inferior turbinate reduction was done. The inferior turbinate was outfractured on the right side with under direct visualization of the 0-degree telescope. The bipolar cautery was then used to cauterize posterior to anteriorly. At the end of this, the Gelfoam was placed where the incision was made along the synechiae band between the middle turbinate and lateral nasal wall. The left nasal cavity was then addressed next after pledgets were removed. The middle turbinate was gently medialized and again synechiae band was noted along the inferior aspect of the middle turbinate in the lateral nasal wall. This was divided and ligated with straight scissors. The left maxillary sinus was then viewed with a 30-degree telescope and it showed some minimal disease noted in the floor of the maxillary sinus well. This was irrigated and suctioned out. Prior to this, cultures were taken of the sinus and sent out for pathology with Lukens trap. Gelfoam was cut in half and then this was placed along the lateral aspect of middle turbinate and lateral nasal wall as well. Postoperative changes were noted in both of the nasal cavities. The nasal cavities and nasopharynx was suctioned. The procedure was then essentially done at this point. Patient tolerated this well and there was no apparent complications. He was awoken by department of general anesthesia at this point and taken to the recovery.
I was thinking 30130 for the rt and 31237 for the lt, but I think I am missing something.
After informed consent was given, risks, benefits and alternatives were discussed with the patient, patient was brought to the operating room and anaesthetized by Department of General Anesthesia. Once this was done, time-out was called correctly confirming the patient and procedure. Afrin pledgets were then placed into the nose, the patient was prepped and draped in usual sterile fashion. The right nasal cavity was then examined first with a 0-degree telescope, 1% lidocaine with 1:100,000 epinephrine was injected along the middle turbinate in the lateral wall. This injection was done similarly on the left side. The right nasal cavity was examined first. There was synechiae band noted between middle turbinate and lateral nasal wall, this was divided with straight scissors and middle turbinate was then medialized with freer elevator. The 30-degree scope was used to examine the right maxillary sinus and photos were taken. There was some minimal disease noted in the floor of the maxillary sinuses otherwise clear at this time. Irrigation was used to irrigate after sinus. Next, the inferior turbinate reduction was done. The inferior turbinate was outfractured on the right side with under direct visualization of the 0-degree telescope. The bipolar cautery was then used to cauterize posterior to anteriorly. At the end of this, the Gelfoam was placed where the incision was made along the synechiae band between the middle turbinate and lateral nasal wall. The left nasal cavity was then addressed next after pledgets were removed. The middle turbinate was gently medialized and again synechiae band was noted along the inferior aspect of the middle turbinate in the lateral nasal wall. This was divided and ligated with straight scissors. The left maxillary sinus was then viewed with a 30-degree telescope and it showed some minimal disease noted in the floor of the maxillary sinus well. This was irrigated and suctioned out. Prior to this, cultures were taken of the sinus and sent out for pathology with Lukens trap. Gelfoam was cut in half and then this was placed along the lateral aspect of middle turbinate and lateral nasal wall as well. Postoperative changes were noted in both of the nasal cavities. The nasal cavities and nasopharynx was suctioned. The procedure was then essentially done at this point. Patient tolerated this well and there was no apparent complications. He was awoken by department of general anesthesia at this point and taken to the recovery.
I was thinking 30130 for the rt and 31237 for the lt, but I think I am missing something.