lurleen78
New
- Messages
- 4
- Location
- Bayville, NJ
Good Afternoon-
I was hoping to obtain opinions on using templates for balloon sinuplasty op reports performed in an office. A practitioner is using the following template for every surgery that is performed:
The patient's nares were topicalized with 4% lidocaine afrin spray. A nasal topicalized with afrin lidocaine pledget. Bilateral injections were carried out with 1% lidocaine epinephrine along the agger nasi regions middle turbinates and inferior turbinates. The middle turbinates were medialized with a cottle forceps. Using the simplicity sinus dilator the left frontal sinus was probed between the ethmoid bulla and uncinate process followed by a 2-5 mm dilation. In a similar fashion the right frontal sinus was probed and dilated from 2-5 mm. The left maxilla os was probed and dilated 2-5mm. The right maxillary os was probed and dilated to 2-5mm. The patient tolerated the procedure well.
Is this enough documentation to support the procedure billed (CPT 31295 LT/RT and CPT 31296 LT/RT). Additionally, is it appropriate to utilize a template that states the same thing for every patient that has this procedure done?
Thanks in advance!
I was hoping to obtain opinions on using templates for balloon sinuplasty op reports performed in an office. A practitioner is using the following template for every surgery that is performed:
The patient's nares were topicalized with 4% lidocaine afrin spray. A nasal topicalized with afrin lidocaine pledget. Bilateral injections were carried out with 1% lidocaine epinephrine along the agger nasi regions middle turbinates and inferior turbinates. The middle turbinates were medialized with a cottle forceps. Using the simplicity sinus dilator the left frontal sinus was probed between the ethmoid bulla and uncinate process followed by a 2-5 mm dilation. In a similar fashion the right frontal sinus was probed and dilated from 2-5 mm. The left maxilla os was probed and dilated 2-5mm. The right maxillary os was probed and dilated to 2-5mm. The patient tolerated the procedure well.
Is this enough documentation to support the procedure billed (CPT 31295 LT/RT and CPT 31296 LT/RT). Additionally, is it appropriate to utilize a template that states the same thing for every patient that has this procedure done?
Thanks in advance!