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microlaryngoscopy with right laser cordotomy

Elaine Posted Thu 12th of July, 2012 14:21:24 PM

How would you code the following:

After adequate general anesthesia was established the patient was examined apneically with the Dedo laryngoscope and intubated through the laryngoscope. The patient's right vocal cord was slightly more edematous and more midline and it was decided that a right transverse cordotomy was performed. After the patient was oxygenated and anesthetized the endotracheal tube was removed. A cotton pledget was placed underneath the vocal cord and using CO2 laser a transverse cordotomy on the right-hand side was performed. This was performed in three sessions with adequate ventilation of the patient in between.

SuperCoder Answered Thu 12th of July, 2012 15:30:59 PM

Depending on whether the otolaryngologist uses a microscope, you should assign 31540 (Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis) or 31541 (... with operating microscope). In a laryngoscopic laser cordotomy, the surgeon removes a tumor and a portion of the patient's underlying vocal cords with a laser. When the otolaryngologist uses a direct laryngoscope to perform the procedure, you should assign 31540. Report laryngoscopic laser cordotomy requiring an operating microscope with 31541.

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