AHA Coding Clinic® for HCPCS - 2022 Issue 3; Ask the Editor

Tracheal stenosis with both laser and dilation techniques

A patient with proximal tracheal stenosis presents for micro suspension direct laryngoscopy with CO2 laser division followed by a repeat balloon tracheal dilation. An anterior commissure laryngoscope was placed and suspended visualizing the larynx. Once the patient was ventilated, the endoscopic telescope was utilized for increased visualization; the laser was used in the stenotic segment along the left lateral aspect and a second cut was made anteriorly.Following the laser division, a 12 mm tracheal balloon was passed under direct visualization and inflated for 1-2 minutes; the balloon was deflated and removed. A second dilation was performed using a 14 mm balloon and dilation was achieved.The tracheal stenosis was treated with laser division and with balloon dilation. Is it appropriate to report both laser and balloon techniques for treating the tracheal stenosis? ...

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