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Otolaryngology Coding Alert


Check for Scope Before Coding Tongue Biopsy

Question: Should I use 42800 or 42802 for the following procedure:

The mass was just in front of the epiglottis to the left of the midline. The mass was removed using a laryngoscope and upbiting cup forceps. The biopsy confirmed a mucocele. Two additional biopsies were taken of the thickened tissue noted on the MRI.

Kentucky Subscriber

Answer: Actually, because the biopsy is performed using a laryngoscope, you should report the mass removal or biopsy from the base of the tongue with 31535 Laryngoscopy, direct, operative, with biopsy).

Codes 42800 (Biopsy; oropharynx) and 42802 (- hypopharynx) describe biopsy without use of a scope. The parenthetical instruction following the family of biopsy codes (42800-42806) says, -For laryngoscopic biopsy, see 31510, 31535, 31536.-

Answers to You Be the Coder and Reader Questions reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

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