Camille Posted Fri 13th of December, 2019 12:23:15 PM
QUESTION: BECAUSE THE TONGUE BIOPSY WAS OBTAINED THRU LARYNGOSCOPE, IS IT INCLUDED IN THE DIRECT LARYNGOSCOPY AND NOT SEPARATELY REPORTABLE? Excerpt from Op Note: "...and general endotracheal anesthesia was induced. The patient was prepped and draped in normal sterile fashion. A thorough examination by palpation was performed of the oral cavity, oropharynx and hypopharyngeal areas. No obvious lesions were identified. Next, direct laryngoscopy was performed. The larynx and vocal cords were normal without lesion. The bilateral piriform sinuses were clear, as well as the post cricoid mucosa. A red rubber catheter was placed through the nares, brought out through the mouth with elevation of the soft palate. Examination by a mirror of the nasopharynx was also clear. Using the laryngoscope, biopsies were obtained of the tongue base; right, left and central biopsies were sent for permanent section analysis. Again, no obvious lesions were noted." THANK YOU VERY MUCH!
SuperCoder Answered Mon 16th of December, 2019 01:18:42 AM
Thank you for your question.
In Direct Laryngoscopy, the patient is appropriately prepped and anesthetized. The provider inserts a laryngoscope into the throat and directly views the laryngeal and hypopharyngeal structures. He then identifies the lesion or other target tissue, grasps a sample, and removes it with an instrument such as cup forceps and sends the sample he has taken to the laboratory for further testing. This procedure is called biopsy.
Now, in your case; since the tongue base biopsy was taken along with direct laryngoscopy, it will be considered inclusive in the laryngoscopy procedure.
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Hope that helps!