AHA Coding Clinic® for HCPCS - 2011 Issue 4; ASK the EDITOR

Endoscopic partial cordectomy versus excision

 A patient with severe dysplasia and carcinoma in situ with possible invasion of the anterior right true vocal fold presents for laryngoscopy with possible biopsy and excision. The patient is given general anesthesia, direct laryngoscopy was inserted and an operating microscope was used for assistance. A biopsy was performed of a vocal cord lesion and the frozen section revealed carcinoma. The same lesion was then excised and then endoscopic partial cordectomy was then performed to ensure that the cancerous lesion had not invaded deeper into the cord. We understand that when a lesion is biopsied and then the same lesion is excised, only the excision would be reported. But in this scenario the excision is then followed by partial cordectomy, which codes to an unlisted code. In this scenario would we report only the endoscopic partial cordectomy or would we report the excision and partial cordectomy? ...

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