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    Bladder Neck Contracture Dilation / attempted contracture incision

    Looking for some advice on the following: PREOPERATIVE DIAGNOSIS: Bladder neck contracture. POSTOPERATIVE DIAGNOSIS: Bladder neck contracture. OPERATION: Cystoscopy, bladder neck dilation, Foley placement, attempted bladder neck incision. INDICATIONS FOR SURGERY: The patient...
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    Cauterization (removal?) of SP polyp

    Looking for some advice on the following procedure: "The patient has a small superficial polyp-like granulomatous growths at the site of the SP tube insertion he would like to have it removed. On exam the patient has a 2 mm x 1 cm granulomatous polyp at the 9 o'clock position. Using initially...
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    Appendix epididymis removal

    Looking for a little help with the following scenario. The physician does a detorsion of the left testicle with fixation of both testicles after that. He also removes a left-sided appendix testes and a right sided appendix epididymis. So far, I've come up with 54600 for the detorsion/fixation...
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    PCNL with additional work (more than 50081?)

    Looking for some advice on the following (the relevant details are in bold): POSTOPERATIVE DIAGNOSIS: Left kidney stones. OPERATION: Left percutaneous nephrolithotomy. The patient has upper pole kidney stones, one of them more medially, approximately 14 mm to 15 mm greatest length on...
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    TURBT with ureteral biopsies

    Looking for some advice on the following: OPERATION: Cystoscopy, transurethral resection of bladder tumor, right diagnostic ureteroscopy with biopsies of right distal ureter, right retrograde pyelogram, and right ureteral stent change. DESCRIPTION OF OPERATION: The patient was identified in...
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    Nephrouterostomy catheter anastomosis pass-through and curling around ileal conduit

    PREOPERATIVE DIAGNOSIS: Stricture at the right ureteroileal conduit anastomosis with right hydroureteronephrosis. POSTOPERATIVE DIAGNOSIS: Stricture at the right ureteroileal conduit anastomosis with right hydroureteronephrosis. OPERATION: Cystoscopy through ileal...
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    Laparoscopy/Laparotomy, reduction of stomach from chest

    Looking for some advice on the following: POSTOPERATIVE DIAGNOSIS: Gastric volvulus with cachexia ANESTHESIA: general anesthesia, single-lumen tube. OPERATION PERFORMED: Gatroscopy with lavage to remove barium followed by laparoscopy and led to laparotomy with mobilization of stomach out of...
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    33282 with 33284

    Quick question re: LINQ recorders. If a patient is having a LINQ replaced, is it appropriate to code both 33284 and 33282 for the removal / replacement procedure? Or is the removal of the old inactive LINQ included in work of 33282? My encoder shows there is a bundling issue, but also states a...
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    Excision of right facial lipoma with facial nerve

    Having some difficulty choosing the correct codes for the following: PREOPERATIVE DIAGNOSIS: Right facial lipoma. POSTOPERATIVE DIAGNOSIS: Right facial lipoma. OPERATION: Excision of right facial lipoma with facial nerve dissection. FINDINGS: Surgical findings were consistent with a...
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    Excision of right facial lipoma with facial nerve

    Having some difficulty choosing the correct codes for the following: PREOPERATIVE DIAGNOSIS: Right facial lipoma. POSTOPERATIVE DIAGNOSIS: Right facial lipoma. OPERATION: Excision of right facial lipoma with facial nerve dissection. FINDINGS: Surgical findings were consistent with...
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    Scar Excision

    Having a little difficulty coding the following. I also posted it in the plastic surgery forum in order to get different perspectives on how to proceed: PROCEDURE PERFORMED: Wide local excision with frozen section margins of previously biopsied positive left cheek basal cell carcinoma and...
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    Scar excision

    Having a little difficulty coding the following: PROCEDURE PERFORMED: Wide local excision with frozen section margins of previously biopsied positive left cheek basal cell carcinoma and local reconstruction. INDICATIONS FOR SURGERY: This is a patient who initially presented to...
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    Umbilical cauterization / no granuloma present

    I am coding the following note: "(umbilical) cord off, healed. Hemorragic discharge. No granuloma. Cauterised with silver nitrate in office." Since there was no granuloma, my question is if 17250 is still appropriate or should I be looking at a destruction code? Any help would be appreciated...
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    Septo/rhinoplasty

    Just a quick question re: septo/rhino procedures for which I've been debating. A patient comes in for a revision rhinoplasty involving osteotomies and nasal tip work. The patient also has septal repair without any cartilage being harvested for the rhinoplasty. Both procedures are stated to be...
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    Non-Medicare Subsequent Observation

    I'm trying to clear up some confusion about the following CPT statement: “For observation encounters by other physicians, see office or other outpatient consultation codes (99241-99245) or subsequent observation care codes (99224-99226) as appropriate.” So I know that for Medicare, only the...
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    Pacemaker Heart Block Diagnosis

    I am trying to process a Medicare claim for a pacemaker implant and the LCD states that the physician's diag of "I45.9-Conduction disorder, unspecified" is not covered. A specific degree of 2 or higher is required to warrant implantation. When I queried the physician, the response I got was that...
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    Turbinate debridement (non-endoscopic)

    Just a quick question re: a follow-up visit I'm reviewing. The provider documents debriding some crust bilaterally from the turbinates after the patient had RFA ablation (30802). He does this without the endoscope, so I know that 31237 does not apply. The patient is beyond the 10-day global...
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    Revision Septorhinoplasty Help

    So I'm debating which way to go on the following (most relevant sections have been highlighted): PREOPERATIVE DIAGNOSIS: Nasal deformity. POSTOPERATIVE DIAGNOSIS: Nasal deformity. OPERATION: Revision of septorhinoplasty with septal cartilage grafting. The patient was taken to...
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    Left lower lobectomy with bronchial / muscle flap repair

    Looking for some advice on the following op report: SALIENT OPERATIVE FINDINGS: Bronchoscopy revealed tumor extending out of superior segment of the lower lobe, but it did not protrude as high as the upper lobe. We performed a VATS procedure. I was concerned that there would be...
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    Ear canal lesion debridement

    I'm looking for advice on the following procedure: ------------------------------------------------------ History from: patient Reason for visit: F/U procedure - e/o R ear canal lesion Pt is here today for excison of right ear canal vascular lesion; has been there for several years and waxes...
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    Skin graft to left ear with debridement prep

    Looking for some advice on the following procedure: Procedure note: Left ear conchal bowl debridement and reconstruction with right post auricular full thickness skin graft Defect size / skin graft size : 1.7 x 1.8 cm left concha cavum Informed consent was obtained. The left ear and right...
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    Cyst excision / hematoma decompression

    Looking for some advice on the following procedure: "After written consent was obtained from the patient, the skin overlying the 3 x 2.5cm mid forehead soft tissue mass was cleaned with alcohol and injected with 3cc of 1% lidocaine with 1:100,000 epinepherine. The mid forehead was then prepped...
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    Endoscopic removal of intranasal synechiae

    I'm trying to code the following procedure and I'm torn as to which way to go: Nasal Endoscopy Type of Endoscope Rigid Indication: left intranasal synechiae Procedure: After verbal consent, the nose was anesthetized with topical oxymetazoline and 4% lidoocaine spray. The endoscope was placed...
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    Panendoscopy with biopsies & Tonsillectomy

    So I'm not 100% confident in my CPT codes for this op report: PREOPERATIVE DIAGNOSIS: Metastatic squamous cell carcinoma to the lymph node, right neck, unknown primary. ANESTHESIA: General endotracheal anesthesia. PROCEDURES PERFORMED: Panendoscopy with biopsies (rigid...
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    Date of service for cath

    Quick question re: cardiac caths. So if the charge is just for the professional component (example: 93458-26), would I bill the date of service as the date of the actual cath or the date that the physician signs the report? I'm running into situations where the report doesn't get signed until...
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    Ear lesion excision / flap reconstruction / abscess drainage

    (I've posted this to 3 forums to get input from a dermatology, plastic surgery and ENT perspective) So I have the following procedure description during an office visit: "HPI: Patient presents for eval for left ear lesion. He has a hx of left auricular abscess that was previously I&D'd and...
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    Ear lesion excision / flap reconstruction / abscess drainage

    (I've posted this to 3 forums to get input from a dermatology, plastic surgery and ENT perspective) So I have the following procedure description during an office visit: "HPI: Patient presents for eval for left ear lesion. He has a hx of left auricular abscess that was previously I&D'd and...
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    Ear lesion excision / flap reconstruction / abscess drainage

    (I've posted this to 3 forums to get input from a dermatology, plastic surgery and ENT perspective) So I have the following procedure description during an office visit: "HPI: Patient presents for eval for left ear lesion. He has a hx of left auricular abscess that was previously I&D'd and...
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    Arytenoid cartilage reduction

    Anyone have input for coding a laryngoscopic reduction of dislocated arytenoid cartilage? The closest I can find is 31560 or 30561, but this is not an exact match since it refers to laryngoscopic >removal< of the cartilage (arytenoidectomy). Should I go with an unlisted code? Any advice would be...
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