Cindy Posted Thu 11th of October, 2012 13:00:11 PM
The surgeon notes in op report:
A direct suspension laryngoscope was inserted and the left tongue base was clearly visualized. The benign looking cyst was exoisionally biopsed with a large cup forcep.
Would you use the 31535 or would you use the 41110. Wasn't sure since 31535 doesn't specify where the lesion is located.
SuperCoder Answered Thu 11th of October, 2012 13:53:49 PM
31535 will still be the correct choice for this.The oral cavity, oropharynx, hypopharynx, larynx, and trachea are examined with the direct laryngoscope,if the lesion is located in any of these structures and biopsy forceps is used to obtain a tissue sample, the code remains valid.In your case Base of tongue relates to the opening of larynx and this code seems correct.