Wiki Control Nasal Bleeding

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tfrick2

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Is there enough in this note to justify billing 31231 & 30901?

"Nose: the septum is deviated to the right side by 70 percent. there are prominent vessels on the right anterior septum. After obtaining permission, the septum was topically anesthetized with 4% lidocaine. Silver nitrate was used to cauterize a superficial vessel. All bleeding was controlled. There were no complications."

Thanks in advance!

Tracy F, CPC, CPC-H
 
If that's all the Dr dictated, no. Also control of bleeding will be included if it was caused by the scope. If Dr wants to code 31231, I suggested seeing the Endoscopy guidelines before 31231 in CPT and make sure Dr is documenting what was inspected and with a scope. Worked with a Dr that got audited and a request for refund because he didn't dictate that he inspected the spheno-ethmoid recess; however, everything else was dictated.
 
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