Question

surgical case 55 i need help coding this cpt code and hcpcs if necassary

Case #55 Operative Report Right true vocal cord lesion ve Diagnosis: Same Procedure: Direct laryngoscopy with excision of right true vocal cond lesion Firm right true vocal cord lesion and some scarring on the fright true vocal cord otherwise normal laryngoscopy This is a 51-year-old man who had a history of anterior commissure nodule that was biopsied in 2001 and came back as benign. He was lost to folow-up, bud returned with increasing hoarseness and was found on fiexible laryngoscopy to for the a mid-right-sided true vocal cord lesion. He was brought to the operating room today for laryngoscopy and removal of this lesion. He was placed in the supine position on the operating room table and mask was esis of the Procedure: anesthesia was induced. Once deeper anesthesia had been achieved, the table was turned toward the laryngoscopy instrumentation. A Dedo laryngpscope was placed carefully into the mouth after the upper gums were protected using wet gauze. The lingual surface of the epiglottis appeared normal as did the vallecula. The laryngeal surface the normal as did the arytenoids and false vocal cords bilaterally. The true vocal cords were bilaterally mobile. They were sightly edematous and there was an approximately 1.5 cm whitish nodule on the right vocal cord in the middle third of the cord. There was a small area of heaped mucosa near the anterior commissure that was sightly hard, but deemed normal and another one at the vocal process that again had normal mucosa, but was slightly frm as if sone ace of the epiglottis also sppeared compienety scarring was present. Again, the left true vocal cord was complenely normal except for slight edema. The posterior commissure area appeared normal. Again, the arytenoids were visualized and were thought to be completely normal. At this point, an LTA was sprayed and the patent was intubated. Completion of the direct laryngoscopy revealed a normal piriform sinus on the left normal postcricoid area and a normal right pirform sinus. At this point, the laryngoscope was replaced such that the right vocal cord was easily visualized and palpated. It was suspended at this time. Next, the operating microscope was brought into place, through the 8400 lens, and the vocal cord was easly inspected and palpated. A right biting forceps was used to retract the md of the right vocal cord and a leftward scissors was used to dissect where this lesion was noted on the vocal cord. This did include the medial aspect of the true coed on that side. Once this was excised in toto, it w sent off for permanent pathology. There was minimal bieeding at the site. The microscope and Dedo laryngoscope were taken out of the field, and the patient was returned to the anesthesia department for reawakening, extubation, and transported to the postanesthesia care unit in a stable condition. Dr Fowler was present for this entire case. Pathology Report and "right true tragment. the Right true vocal cord lesion One specimen is received in formalin labeled with demographics vocal cord." It consists of a 0.230.1 3 0.1 m white tse Specimen: Gross description: specimen is stained with eosin and entirely submitted n Squamous mucosa with focal moderate dysplasia submitted in one Examination/ agnosis: Code(s):. Index entries:

Answer 1

ICD -10-CM CODE is the tenth version of international classification of diagnosis . It is used by the healthcare workers to code a diagnosis and insurance company's to code a disease for reimbursement purpose .

CPT code is the current procedural terminology . It is used to code a procedure .

ICD -10-CM for right true vocal cord lesion is J38.3

CPT code for direct laryngoscopy with excision of right true vocal cord lesion is 31450