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Is Scar Revision Still Complex Closure?
I have a scar revision for the abdomen and was going to assign CPT 13101. My coding teammate told me this is no longer the current coding recommendation. Is scar revision still reported with complex closure?
Secondary CSF leak following skull base surgery
Patient had to be taken back to the OR a day after an open skull base procedure due to a cerebrospinal fluid leak, and the dura was repaired with a synthetic graft material. What is the correct CPT code for the repair, if it is separately reported, and do we need a modifier?
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?
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