Hi all~ My doctor performed 30520 septoplasty (90 day global), 31255 & 31267 (no global) for sinuses. Patient comes in this month and this is the exam:
VITAL SIGNS
Height: 63 in.
Tobacco Use: never
Allergies reviewed - no changes
OFFICE NOTE
CHIEF COMPLAINT: Patient returns to the office today in follow up, status post nasal septoplasty, bilateral total ethmoidectomies and left maxillary sinusotomy with tissue removal.
HISTORY OF PRESENT ILLNESS: Patient reports ongoing "sinus headaches." She denies any purulent rhinorrhea or fevers. She does remind me that she has multiple types of headaches, including migraines, etc.
She indicates that she is irrigating 2-3 times per day.
PHYSICAL EXAMINATION: Anterior rhinoscopy reveals clear nose and midline septum.
The patient's sinuses were examined endoscopically. Both ethmoid sinuses bilaterally as well as the left maxillary sinus. The patient's sinus surgery defects are healing nicely. There is no evidence of any infection, bleeding, etc.
IMPRESSION:
1) Satisfactory postoperative course.
RECOMMENDATIONS:
1) Patient will continue to irrigate at least two times per day. We have asked her to return to see us on the three-month anniversary to surgery, some time in late July.
PROCEDURE NOTE
PROCEDURE: Nasal/sinus endoscopy; bilateral ethmoid and left maxillary sinus endoscopy.
SURGEON:
ANESTHESIA: Topical Lidocaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Zero.
FINDINGS: Included .
PROCEDURE: Following adequate Lidocaine spray analgesia, the patient's nasal cavities bilaterally, as well as ethmoid cavities bilaterally and left maxillary sinus carefully inspected using the fiberoptic endoscope. The above findings were noted.
Patient tolerated the procedure well. There were no complications.
I thought we should only bill 31233-79-50 and link sinus dx and 99024 and link dx for septoplasty because there is a component of E/M factored in to the 31233 code.
He says that his academy fought for the codes 31255 & 31267 to not have a global and this essentially leaves him as having a global period because he can't bill a 992_ _-24 on this visit. I feel the documentation does not support a separate & identifiable E/M service.
What do you think? All help is appreciated, Thanks!
VITAL SIGNS
Height: 63 in.
Tobacco Use: never
Allergies reviewed - no changes
OFFICE NOTE
CHIEF COMPLAINT: Patient returns to the office today in follow up, status post nasal septoplasty, bilateral total ethmoidectomies and left maxillary sinusotomy with tissue removal.
HISTORY OF PRESENT ILLNESS: Patient reports ongoing "sinus headaches." She denies any purulent rhinorrhea or fevers. She does remind me that she has multiple types of headaches, including migraines, etc.
She indicates that she is irrigating 2-3 times per day.
PHYSICAL EXAMINATION: Anterior rhinoscopy reveals clear nose and midline septum.
The patient's sinuses were examined endoscopically. Both ethmoid sinuses bilaterally as well as the left maxillary sinus. The patient's sinus surgery defects are healing nicely. There is no evidence of any infection, bleeding, etc.
IMPRESSION:
1) Satisfactory postoperative course.
RECOMMENDATIONS:
1) Patient will continue to irrigate at least two times per day. We have asked her to return to see us on the three-month anniversary to surgery, some time in late July.
PROCEDURE NOTE
PROCEDURE: Nasal/sinus endoscopy; bilateral ethmoid and left maxillary sinus endoscopy.
SURGEON:
ANESTHESIA: Topical Lidocaine.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Zero.
FINDINGS: Included .
PROCEDURE: Following adequate Lidocaine spray analgesia, the patient's nasal cavities bilaterally, as well as ethmoid cavities bilaterally and left maxillary sinus carefully inspected using the fiberoptic endoscope. The above findings were noted.
Patient tolerated the procedure well. There were no complications.
I thought we should only bill 31233-79-50 and link sinus dx and 99024 and link dx for septoplasty because there is a component of E/M factored in to the 31233 code.
He says that his academy fought for the codes 31255 & 31267 to not have a global and this essentially leaves him as having a global period because he can't bill a 992_ _-24 on this visit. I feel the documentation does not support a separate & identifiable E/M service.
What do you think? All help is appreciated, Thanks!
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