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Discrepancy between Procedure Title and Documentation Details
If the details of a procedure documentation do not match the listed procedure/operation that was planned, which procedure code should be selected?
Co-Planing of AC Joint
Our surgeon documented co-planing of the AC joint/distal clavicle. The diagnosis is bone spurs. Does this work support CPT code 29824, arthroscopic distal claviculectomy?
Prescription Drug Management
Every patient I see is in pain, and I discuss prescription medications (primarily prescription NSAIDs, Neurontin, and/or muscle relaxers) with almost every patient. If I document “discussed prescription drug management with Mobic, patient defers and will continue Motrin OTC as needed.” Is this prescription drug management?
Swimmer’s Ear
I am new to ENT coding and am not certain what code I would use. The physician placed an oto-wick in the left ear using the microscope on a patient with swimmer’s ear. Do I just report the microscope code 69990 or do I use a different CPT code?
Donor or recipient site?
I’m a newbie plastics coder and still learning. Are muscle flaps coded to the recipient site or by the donor site?
Number and Complexity of Problems Addressed
I see a number of patients with chronic problems such as dermatitis, psoriasis, history of skin cancer and acne to name a few. What defines stable versus exacerbation or progression?
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