1. Assign the ICD-10-cm code(s) to diagnosis and conditions and assign the CPT surgery code (s )
and the appropriate HCPCS level11 and CPT modifier(s). Do NOT assign ICD-10-CM external
cause codes.
preoperative diagnosis: lesion of vocal cords postoperative diagnosis: tumor of the left vocal cord
operation performed: laryngoscopy
the patient was a 25 year old student of opera who presented with lesion of the left vocal cords
seen on office laryngoscopy. Today she was seen in the ambulatory suite for further examination
of this lesion, using the operating microscope. After the administration of local anesthesia, a direct
endoscope was introduced. The operating microscope was brought into the field, and the pharynx
and larynx were visualized. The pharynx appeared normal. There was a mass noted of the left
vocal cord. The mass was approximately 2.0 cm in size and was removed in total and sent to
pathology for analysis. All secretions were suctioned, and the area was irrigated with saline. The
patient had minimal blood loss. It should be noted that the pathology report stated benign tumor of
the vocal cord