3. Operative Report PREOPERATIVE DIAGNOSIS: Chronic laryngitis with polypoid dis
ID: 244872 • Letter: 3
Question
3. Operative Report PREOPERATIVE DIAGNOSIS: Chronic laryngitis with polypoid disease POSTOPERATIVE DIAGNOSIS: Same PROCEDURE: Laryngoscopy with removal of polyps After adequate premedication, the 60-year-old female patient was taken to the operating room and placed in supine position. The patient was given a general oral endotracheal anesthetic with a small endotracheal tube. The Jako laryngoscope was then inserted. Large polyps were noted on both vocal cords, essentially obstructing the glottic airway when the tube was in place. The polyps appeared larger on the right cord. Using the straight-cup forceps, the polyps were removed from the left cord first. The polyps were removed from the right cord up to the anterior commissure. Very minimal bleeding was noted. This opened up the airway extremely well. The patient was extubated and sent to recovery in good condition.
3. a.How many ICD-10-PCS codes are necessary for complete coding of this case?
b.What is (are) the code(s)?
c. Are any guidelines pertinent to the coding of this case?
Explanation / Answer
a).Two codes are enough to know the case.
b).1.J38.1 is the code indicating the diagnosis.
2.CPT31541 is the code indicates the procedure (excision from larynx it can be a mass or polyp not an cancerous mass or biopsy).
c).In previous codes so many codes need to be add.But from 2017 this codes will enough to know the case.
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