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Topic Title: Left Vocal Cord Cyst Excision
Topic Summary: CPT Code Needed for PX
Created On: 10/05/2007 12:08 PM

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 10/05/2007 12:08 PM
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khill2140

Posts: 51
Joined: 03/13/2007

Any help w/CPT Code(s)/Modifier(s) for the following procedure would be greatly appreciated: (Considering 31541 or 31545 but neither seem correct)

FINDINGS: A large Reinke's space cyst occupying most of the left vocal cord surface. The right vocal cord appears to be normal. The subglottic region, the trachea down to the carina all appeared normal. The supraglottic structures appear to be normal.
INDICATIONS FOR SURGERY: Long history of smoking, acid reflux disease, talkativeness and hoarseness for at least a year. She was preoperatively evaluated in the ENT Clinic, flexible fiberoptic laryngoscopy revealed a large prolapsing cyst that was moving up and down with respiration and vocalization. It was located in the medial part of the vocal cords mucosa on the left side. The patient was extensively counseled, her questions were all answered preoperatively, risks and benefits were discussed, legal consent was obtained preoperatively.
DESCRIPTION OF PROCEDURE: On the day of surgery, the patient was brought to the operating room and was placed in a supine position. She received 10 milligrams of Decadron intravenously on call. The patient's table was turned 90-degrees away from anesthesia. A shoulder roll was placed. The head was prepped and draped in a common manner for direct laryngoscopy and bronchoscopy. Miller blade laryngoscope was used to inspect the patient's supra-glottis. This was done after the patient's identification and verification of consent was made. The patient's larynx was sprayed with Lidocaine Spray. After adequate time had elapsed, the Miller blade laryngoscope was introduced once again into the patient's supraglottic structures, secretions were suctioned clear, 0-degree 4 millimeter scope was introduced into the supraglottic structures, the vocal cord cyst was clearly identified on the left vocal cord prolapsing up and down with respirations, the scope was advanced further to the subglottic region, which appeared to be normal, it was then pushed all the way down to the carina, other than minimal secretions there was no pathological findings. The patient was intubated with a #6 cuffed endotracheal tube, after securing the airway, a suspension Karl Storz anterior commissure laryngoscope was gently inserted into the supraglottic structures, it was suspended away and fixed into a position demonstrating the entire length of both vocal cords. The microscope was brought into the field, the cyst was grabbed with forceps on its medial side and sickle knife was used to make a small incision on the roof of this cyst. The mucoid amber colored content was suctioned clear. Redundant cyst mucosa was then cut with right biting scissors. Only the roof of this cyst was removed and caution was taken not to injure the medial surface of the vocal cord mucosa. Two different specimens from this redundant mucosa were sent to pathology. The surgical field was inspected, it was found to be hemostatic. Neurosurgical pledgets were placed in place for 2 minutes in order to verify absolute hemostasis. After this was achieved, the laryngoscope was gently withdrawn from the patient's supraglottic region. The mouthguard that had been there protecting her upper jaw teeth was removed.
Thanks!

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Thanks!
Kayla
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 10/05/2007 04:17 PM
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16562372

Posts: 3
Joined: 08/16/2006

I am not positive on this, but I would code it with 31541 - LT
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 10/05/2007 06:15 PM
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khill2140

Posts: 51
Joined: 03/13/2007

Thanks!

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Thanks!
Kayla
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