The physician billed the following CPT code 30901 and 31231. I don't think correct.
Pt seen 1 week ago and had silver nitrate cautery of bilateral septal bleeding points following multiple episodes of bleeding and cautery by Dr. XXXXX.* Pt had also been seen in ER where tissue packing removed from nose - no active bleeding at that time.
Presents now with recurrent right sided bleeding earlier this week - minor, self-limited, has not bled in 2 days.* Has not resumed anticoagulation yet.
PE: *****(+) fibrinous exudate covering healing cautery sites, bilaterally* ---> gently removed with suction; no bleeding on left, very minimal oozing on right
A/P:*****Recurrent right sided bleeding following cautery (minimal)
************Bleeding points appear to be healing well - pt reassured
************Very minimal cautery repeated on right; gel foam placed, bilaterally
************Continue use of moisturizing ointment
************Resume anticoagulation as per Dr. XXXX
************Follow up PRN
Pt seen 1 week ago and had silver nitrate cautery of bilateral septal bleeding points following multiple episodes of bleeding and cautery by Dr. XXXXX.* Pt had also been seen in ER where tissue packing removed from nose - no active bleeding at that time.
Presents now with recurrent right sided bleeding earlier this week - minor, self-limited, has not bled in 2 days.* Has not resumed anticoagulation yet.
PE: *****(+) fibrinous exudate covering healing cautery sites, bilaterally* ---> gently removed with suction; no bleeding on left, very minimal oozing on right
A/P:*****Recurrent right sided bleeding following cautery (minimal)
************Bleeding points appear to be healing well - pt reassured
************Very minimal cautery repeated on right; gel foam placed, bilaterally
************Continue use of moisturizing ointment
************Resume anticoagulation as per Dr. XXXX
************Follow up PRN
