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Risk of Patient Management
Our new surgeon wants to code a level five encounter for all patients where the patient is scheduled for inpatient surgery. He states he was educated that all outpatient surgeries are automatically a level four encounter, and all inpatient surgeries are automatically level five encounters. Have we been assigning the level of risk incorrectly?
Thoracic Calcified Disc
The documentation indicates a costovertebral approach and rib removal to access and dissect a calcified thoracic disc at T9-T10. How is this coded? And can the rib removal be reported separately?
Septoplasty with a Nasal Swell Body Reduction
I performed a Septoplasty for a patient with a deviated nasal septum. During the procedure, I also performed a nasal swell body reduction on the septal mucosa. My coder told me I could report 30520 for the Septoplasty but I could not report the lesion excision with 30117. I don’t understand why I cannot report both codes together. Can you advise?
13160 in Addition to Tendon Repair?
We have a patient who sustained a laceration that was repaired in an emergency room. The patient now presents to our plastic hand surgeon to repair a lacerated tendon. The previously closed wound is opened, and the tendon repair is performed. Would it be appropriate to report 13160 in addition to the tendon repair CPT?
First Patient Encounter
I saw a new patient in the outpatient clinic several weeks ago. Now, the patient has been admitted to the hospital. The admitting physician has asked me to see the patient again for that same condition. This is my first time seeing them in the hospital for an inpatient visit. What EM code do I bill for this visit?
E/M Level When Patient is Non-compliant With Treatment Advice
An established patient presents to my office with severe exacerbation of an existing condition, and I recommend they be urgently transferred to the ER for admission. The patient refuses and prefers to leave against my medical advice. May I still bill a level 5 E/M for a high level problem that requires hospitalization and urgent intervention?
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