tci ED Coding & Reimbursement Alert - 2013 Issue 4
You Be the Coder: Secrets of Selecting the Sialolithiasis Service Code
Question: The patient is a 54 year old female who presents with right sided face pain. ENT exam shows a 1 mm stone on the right buccal region of the mucosa. The ED physician documented a diagnosis of sialolithiasis with the following procedure note: Procedure note Location: inner right cheek. Confirmed: Patient, procedure, side, and site correct, Time-out taken prior to procedure. Procedure: removal of stone from the right mucous membrane, scalpel # 15 used to incise the bulging right buccal mucosa with the stone tip in view. Procedural sedation: None. Patient tolerated: Well. Complications: None. Performed by: EDMD...
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