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mass of tonsil

  1. #1
    Location
    NEW ORLEANS
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    954
    Default mass of tonsil
    Exam Training Packages
    anyone ever coded a mass on a tonsil ?If so, what code did you use

  2. Default
    What sort of mass?
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC
    www.ncspecialty.com

  3. #3
    Location
    Albany, New York
    Posts
    456
    Smile
    Based on the info you provide in your inquiry, I would go with 474.9
    Karen Maloney, CPC
    Data Quality Specialist

  4. Default
    Path sent? 474.9?

  5. #5
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    ENGLEWOOD/DENVER
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    2,338
    Default
    are you looking for CPT code or DX code?

  6. #6
    Location
    NEW ORLEANS
    Posts
    954
    Default
    Cpt Code , Path Came Back As 795. 4

  7. #7
    Location
    ENGLEWOOD/DENVER
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    2,338
    Default
    Quote Originally Posted by trent123 View Post
    Cpt Code , Path Came Back As 795. 4
    For the CPT we will need additional info. Can you post the note?

  8. #8
    Location
    NEW ORLEANS
    Posts
    954
    Default
    PROCEDURE : Excision of mass, right tonsil

    The patient was taken to operating room , under general endotracheal aneesthesia, was prepped and draped. The Croer -Davis mouth gag was inserted, and the oropharynx was visualized directly. The patient had a papillomatous mass of right tonsil. This was removed with sharp dissection. Hemostasis was achieved with electrocautry. The patient also had a tonsillith of left tonsil. This was removed with an alevator., A small amount of bleeding was controlled with suction cautery as well

  9. Default
    I am thinking 42808 x2, one for the right and one for the left side. Any other thoughts?

    Susan

  10. #10
    Location
    ENGLEWOOD/DENVER
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    I will have to agree with Susan...

    UNLESS (I think this is very poor documentation by the way). Did the pathology report happen to indicate that the tonsils were removed completely or really just these lesions? I am having a hard time thinking/believeing that they just removed these lesions and not electing to just remove completely.

    Also on the diagnosis....if the 795.4 what was printed on the pathology report and coded by them? If so, I would not use that. What exactly does the pathology report read for the diagnosis of the pathology submitted?

    the not convinced
    Mary, CPC, COSC

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