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need help coding

  1. #1
    Chesapeake City Chapter
    Default need help coding
    Exam Training Packages
    Op report reads

    1. Adenotonsillectomy
    2. Endoscopy with biopsy/drainage of vellecular cyst

    (I coded the Adenotonsillectomy)

    The base of the tongue was inspected and there was a firm 1.5x1cm rounded lesion on the left midline region of the vallecula consisten with a valleccular cyst. The superior posterior aspect of the this cyst was biopsied and sent to pathology. In the process of biopsying this area, a thick, gelatinous substance was expressed and the cyst decompressed quickly. Futher debridement was carried out over the superior aspect of the cyst hoping to marsupialize it to prevent recurrence.

    Direct laryngoscopy was then extended further inferiorly. The hypopharynx was normal. The vocal cords were without lesions. The stomach was then suctioned.

    Not sure if biopsy (41105) is my only code before laryngoscopy.

  2. Default
    Personally, I would bill the T & A (42820 or 42821, age appropriate) and 31535for the laryngoscopy w/biospy, the decompression of the cyst was incidental to the biospy.

    Jennifer, CPC

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