Inpatient Facility Coding & Compliance Alert

You Be the Coder:

Look for This to Select Correct Sialolithiasis Service Code

Question: The patient is a 54-year-old female who presents with right-sided face pain. ENT exam shows a 1 mm stone on the right buccal region of the mucosa. The ED physician documented a diagnosis of sialolithiasis with the following procedure note: 

Location: inner right cheek. Confirmed: Patient, procedure, side, and site correct, Time-out taken prior [...]
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