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A patient presented for hysteroscopic removal of their intrauterine device (IUD). On examination in the office, the IUD strings could not be visualized in the vagina or passing through the cervix; ...
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A patient presents to surgery one week post complete mastectomy, for re-excision of positive muscle margins. The patient was thought to have residual tumor invading the skeletal muscle involving th...
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A patient with a history of breast reconstruction now has a chronic wound of the left breast with impending implant exposure. Per the provider, the patient presented to surgery for left breast impl...
For facility...
After a patient had an initial pelvic examination under anesthesia, attention was turned to laparoscopic access and a supraumbilical incision was made. Trocars were introduced and examination revea...
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The patient, whom had a previous L4-S1 fusion and an auto-fusion of T12-L1, has now developed spinal stenosis of L1-L4 and presented for decompression. After a posterior midline incision was made t...
Based on the...
At our facility, the nurses now perform minor services for the patient (such as, suture removal, immunizations, wound check, etc.,). Would it be appropriate to report the services provided by the n...
Yes, it is a...
When would it be appropriate to append modifier -59 to a procedure? This patient comes into the Emergency Room and an Abdomen Series and Intravenous Pyelogram are ordered together. According to the...
Yes. The mod...
Periodically we see patients who are scheduled for drug therapy. However, sometimes the physician may cancel an encounter following review of lab or radiology reports. What is the policy regarding ...
There was no...
We are looking for guidance regarding the reporting of splints under APC’s. Would an aircast qualify for facility coding for splints? Would immobilizers qualify for strappings and are splints con...
Yes, strappi...
This patient had a diagnosis of extensive fourth degree hemorrhoids. The findings revealed large internal thrombosed hemorrhoids. According to the operative report an elliptical incision was made a...
According to...