How would you code this:
Clinical: hypertrophy of tonsils and turbinates, sleep apnea, deviated septum.
Gross: ..two undesignated tonsils which each weigh 3 grams....along with an additonal portion of ...glistening soft tissue measuring 2x1.5x0.8cm...
Micro: Tonsils and squamous mucosa, right and left tonsil and portion of palate:
Tonsils; follicular hyperplasia (chronic hypertrophic tonsillitis).
Palate; squamous mucosa with underlying salivary glands with no significant histopathologic changes
Of course it'll be 88304 x1 for the two tonsils together.
I wonder if the documentation supports an additional code for the palate/salivary glands? Thoughts?
Thanks!
Megan
Clinical: hypertrophy of tonsils and turbinates, sleep apnea, deviated septum.
Gross: ..two undesignated tonsils which each weigh 3 grams....along with an additonal portion of ...glistening soft tissue measuring 2x1.5x0.8cm...
Micro: Tonsils and squamous mucosa, right and left tonsil and portion of palate:
Tonsils; follicular hyperplasia (chronic hypertrophic tonsillitis).
Palate; squamous mucosa with underlying salivary glands with no significant histopathologic changes
Of course it'll be 88304 x1 for the two tonsils together.
I wonder if the documentation supports an additional code for the palate/salivary glands? Thoughts?
Thanks!
Megan